Every finding on record at Surrey Place St Lukes Hospital Skilled Nursing

See the deficiency cited at LUGT12. Based on interview and record review, the facility failed to ensure residents were free from significant medication error after one resident with an allergy to penicillin (a class of antibiotics that are commonly used to treat bacterial infections) was ordered and administered Zosyn (a penicillin antibiotic used to treat infections) intravenously (IV, into the vein) to treat a urinary tract infection (UTI) (Resident #503). The facility failed to get a detailed account of the resident's reaction to penicillin after it was reported and the resident's reactions were not documented in the medical record. The resident's family reported to facility staff the resident's reaction to penicillin was blood clots, he/she was highly allergic, and it could kill him/her. The nurse reported he/she was informed the resident's reaction was only blood clots. The pharmacy and the physician were informed the resident's reaction were only blood clots. The resident was administered Zosyn IV and thirty minutes later, he/she had difficulty breathing, was administered four liters of oxygen, and was transported to the emergency room . The resident was diagnosed with anaphylaxis (a severe, potentially life-threatening allergic reaction), was noted to be hypoxic (a condition that occurs when the body or part of the body does not receive enough oxygen at the tissue level) and was administered two rounds of epinephrine (adrenaline, emergency treatment for severe allergic reactions including anaphylaxis caused by unknown substances). The sample was four residents. The census was 65 with 52 in certified beds.

Based on interview and record review, the facility failed to ensure residents were free from significant medication error after one resident with an allergy to penicillin (a class of antibiotics that are commonly used to treat bacterial infections) was ordered and administered Zosyn (a penicillin antibiotic used to treat infections) intravenously (IV, into the vein) to treat a urinary tract infection (UTI) (Resident #503). The facility failed to get a detailed account of the resident's reaction to penicillin after it was reported and the resident's reactions were not documented in the medical record. The resident's family reported to facility staff the resident's reaction to penicillin was blood clots, he/she was highly allergic, and it could kill him/her. The nurse reported he/she was informed the resident's reaction was only blood clots. The pharmacy and the physician were informed the resident's reaction were only blood clots. The resident was administered Zosyn IV and thirty minutes later, he/she had difficulty breathing, was administered four liters of oxygen, and was transported to the emergency room . The resident was diagnosed with anaphylaxis (a severe, potentially life-threatening allergic reaction), was noted to be hypoxic (a condition that occurs when the body or part of the body does not receive enough oxygen at the tissue level) and was administered two rounds of epinephrine (adrenaline, emergency treatment for severe allergic reactions including anaphylaxis caused by unknown substances). The sample was four residents. The census was 65 with 52 in certified beds. Review of the facility's Medication Orders Policy, reviewed February 2021, showed: -Policy: Medication Orders shall be clear and accurate. Practitioners with delineated clinical privileges shall be able to give orders. Written patient medication orders for treatment shall be dated, timed and signed by the prescriber. All other medication orders will be entered into the hospital computer system via CPOE. Orders entered by a non-physician, shall be countersigned by the ordering physician; -Process for Accepting a Telephone Order: The hospital minimizes the use of verbal and telephone medication orders. Only authorized prescribers can give telephone orders; -Telephone orders are permitted. When taking a telephone order, the listener will type the order into CPOE. The listener will read the entire transcribed order back to the prescriber, including the patient's name and will use words instead of abbreviations. The prescriber will countersign the telephone order; Telephone orders are not to be taken for anti-neoplastic agents, except to discontinue or hold the antineoplastic agent. A telephone order that seems inconsistent with the patient's problem will be questioned/clarified before the order is implemented; -Preprinted and electronic standing orders, order sets, and protocols for medication orders include the following Processes for use: Review and approval of standing orders and protocols by the medical staff and the hospital's nursing and pharmacy leadership; -Evaluation of established standing orders and protocols for consistency with nationally recognized and evidence-based guidelines; -Regular review of such standing orders and protocols by the medical staff and the hospital's nursing and pharmacy leadership to determine the continuing usefulness and safety of the standing orders and protocols; -Dating, timing, and authenticating of standing orders and protocols by the ordering practitioner or another practitioner responsible for the patient's care in accordance with professional standards of practice; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations. Review of Resident #503's face sheet, showed: -admitted on [DATE]; -Admit reason: Covid positive, fever, acute urinary retention, weakness, failure to thrive, malnutrition, congestive heart failure exacerbation; -Allergies: Penicillin and Zosyn. Review of the resident's allergy list, updated [DATE], showed: -Penicillin: Reaction: anaphylaxis; -Zosyn: Reaction: anaphylaxis. Review of the resident's allergy list, provided by staff and received on [DATE], showed: -Penicillin: Reaction: Cancelled; -Updated: [DATE]; -Source: Family; -Received: [DATE]; -A handwritten note showed, allergy status was cancelled in 2017. It was reviewed as cancelled again on [DATE] because of it being listed in history once reviewed and confirmed as cancelled medication order continued/medication administered. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated [DATE], showed: -Diagnoses included atrial fibrillation (a-fib, irregular heartbeat), heart failure, hypertension (HTN, high blood pressure), benign prostate hyperplasia (BPH, a non-cancerous enlargement of the prostate gland), hyperlipidemia (abnormally high levels of lipids or fats in the blood), dementia, malnutrition and anxiety; -Severe cognitive impairment; -Has physical behaviors; -Incontinent of bowel and bladder; -Administered anticoagulant (medication that reduces blood clots), antibiotic and anti-anxiety medications. Review of the resident's care plan, initiated [DATE], showed: -Plan: Long term care genitourinary (urinary and genital organs) Interdisciplinary Plan of Care (IPOC); -Intervention: Monitor symptoms of UTI (voiding pain, mental status change) and notify nurse if present; -Note urine color, clarity, amount, odor; -Promote optimal fluid and nutrition intake intervention: Provide perineal care (peri care, washing the genitals and anal area); -Notify physician for variations in evaluation findings. Review of the physician's progress notes, dated [DATE], showed: -Patient concerns: Recent UTI greater than 100,000 colony forming units (cfu)/ milliliter (ml) Citrobacter Koseri (bacteria), this is a multi-drug resistant (MDRO) that is resistant to three or more class of antibiotics. Contact precautions are required. Consider an infectious disease consult if indicated; -Impression and Plan: UTI - Citrobacter Koseri; -Plan: Start Nitrofurantoin (Macrobid, antibiotic used to treat and prevent urinary tract infections). Review of the physician progress notes, dated [DATE], showed: -Patient concerns: Follow up of UTI, tolerating Macrobid, gets very agitated on day to day treatments, follow up of labs; -Impression and Plan: Potassium 5.1 (normal potassium level for adults, 3.5 to 5.0) and blood urea nitrogen (BUN, measures kidney function) 44 ( normal BUN level, 8 to 23 milligrams per deciliter for adults over 60); -Lokelma (used to treat high potassium levels) 10 grams (g) by mouth x one now; -Increase oral fluids; -UTI - Citrobacter Koseri; -Plan: Start Nitrofurantoin, Lokelma x one dose. Review of the physician progress notes, dated [DATE], showed: -Patient concerns: Follow up of UTI, tolerating Macrobid, more calm, cooperative, no chest pain, headaches, cough, nausea, vomiting, diarrhea, fever; -Impression and Plan: UTI - Citrobacter Koseri on Macrobid; -Plan: Start Nitrofurantoin, repeat urinalysis (UA, a test that examines urine to detect and manage a range of disorders) and culture. Review of the physician progress notes, dated [DATE], showed: -Patient concerns: Follow up UA and culture and sensitivity (C&S), still showing white cells and bacteria, more compliant; -Impression and Plan: UTI - Citrobacter Koseri on Macrobid completed will repeat UA, still showing bacteria and white cells; -Will start him/her on Zosyn 3.375 gram (g) every 8 hours; -Plan: Will start Zosyn 3.375 every 8 hours for five days. Review of the progress notes, showed: -Service date/time: [DATE] at 6:00 P.M.; -Performed by Assistant Director of Nursing (ADON) on [DATE] at 8:42 P.M.; -Signed by ADON on [DATE] at 8:42 P.M.; -Received call from pharmacy stating that Physician A wanted to start the patient on IV Zosyn. Patient's chart stated that he/she had an allergy to penicillin and the pharmacist asked me to ask patient or family what the reaction was. Son stated that the reaction was that it caused blood clots. Pharmacist stated that Zosyn does not cause blood clots and that we were ok to hang the IV. Review of the resident's progress note, signed by the ADON on [DATE] at 8:42 P.M., provided by staff and received [DATE], showed a handwritten note, Nurse did talk to son, the source of history of antibiotic allergy which was cancelled in 2017 and son stated that the reason was that it caused blood clots. This information was reported to doctor and pharmacist and medication was cleared and approved for administration. Review of the progress notes, showed: -Service date/time: [DATE] at 11:43 P.M.; -Signed by Licensed Practical Nurse (LPN) B on [DATE] at 11:49 P.M.; -This nurse started patient on Zosyn IV as ordered. After 30 minutes of going back into the room to check on the patient, noticed that he/she was not him/herself. Patient stated that he/she did not feel good and he/she was yelling out, serum pressure oxygen (SPO2) was low, this writer applied oxygen at 4 liters (L) via nasal cannula, blood pressure was not reading. Physician A called left voicemail (LVM). Son called, made aware of resident's condition, and 911 called to have patient sent to hospital. Review of the progress notes, showed no documentation of the resident's behavior on [DATE], resident's signs and symptoms of allergy to penicillin, conversations between the resident's family and nursing staff, and conversations between nursing and pharmacy or physician. Review of the resident's hospital record, dated [DATE] at 11:35 P.M., showed: -Chief Complaint: Nurse hung antibiotic at rehab. Thirty minutes later, patient had respiratory rate and complaints of burning sensation. Patient is a Do Not Resituate (DNR, medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing or heart stops); -History of present illness: The onset was prior to arrival. He/She is an [AGE] year-old who is being treated at rehab facility for pneumonia. He/She was getting antibiotics and 30 minutes later when the staff went to check on, he/she was found less responsive and was having some difficulty breathing. Paramedics were called. Emergency Medical Service (EMS) report is not available. The prearrival report suggests that he/she was hypotensive (low blood pressure) and heart rate of 110. He/She was given two rounds of epinephrine intramuscularly (within or into a muscle). He/She was not noted to be wheezing. He/She was noted to be hypoxic (a condition that occurs when the body or part of the body does not receive enough oxygen at the tissue level). He/She was put on nonrebreather (a medical device that provides oxygen to patients in emergency situations) mask. Patient cannot provide any history. Further information as noted above in the triage; -EMS report: allergic reaction to intravenous line (IV) antibiotics, from rehab, 2 IM cpi given; -Vitals: ,d+[DATE] (low blood pressure is a reading lower than ,d+[DATE]); -110 a-fib, unable to get O2 (oxygen); -Spoke with his/her son who is present at the bedside. Apparently visited him/her this afternoon and he/she was not feeling good at that time. He/She was not feeling well. He told the surgery place that he/she gets blood flow from penicillin. No other reaction was noted. DNR/DNI (Do Not Intubate) was confirmed with the son. During an interview on [DATE] at 12:18 P.M., the ADON said pharmacy called from the hospital. The resident had the allergies to penicillin and pharmacy asked if the resident would be able to tell them what happened. The resident could not. His/Her son was reached and the son said it almost killed him/her and gave (him/her) blood clots. They got an IV in him/her, and even pharmacy recommended running it slower, but the ADON could not confirm that for sure. They started that night, but he/she had a reaction and they sent him/her out 911. The ADON was not there at the time the resident was sent out. Physician A was contacted. The ADON looked for the note in the medical record. He/She said it happened a long time ago, but confirmed there was no other note on him/her and if there was no documentation, he/she did not want to say the physician was notified. The ADON already left when resident had a change in condition. LPN B hung the IV. LPN B was upset that the information was not conveyed to him/her regarding the reaction to penicillin. They stayed with the resident the first few minutes and for a regular antibiotic, they do checks for the first two hours. It's visually assessing the resident, eyes on the resident. The pharmacy said the allergy to penicillin was in there, but the severity was not documented, so that was why they wanted to contact someone in the family. The ADON did not remember if he/she took the order for the medication. The son said blood clots first, but pharmacy said it was not possible. The ADON went back to the son and said it was not on the list of reactions and not possible. The son said I am not medical, but the son said the blood clots. The ADON did not have almost killed him/her documented, but he/she realized he/she said it in the beginning of the interview. He/She did not want to say that for sure. The pharmacy called the facility. Someone else could have put the order in. The ADON checked the medial record and said the order was put in by Physician A, from what the ADON was able to see. The ADON was asked if he/she felt comfortable administering the Zosyn. The ADON said with the pharmacy saying it was ok, he/she felt comfortable administering medication. Anytime there is a new medication, they keep an eye on the resident whether it is a possible allergy or not. There is no protocol if there was uncertainty of symptoms or reaction to a medication. It should be the same situation with any antibiotic administered. They keep an eye on the resident. During an interview on [DATE] at 1:57 P.M., the Director of Pharmacy returned to the record in their system. The resident was allergic to penicillin, but no reaction was listed. They did put the order through. They talked to Physician A and he/she said the resident was resistant to all medications for a UTI, so the only option was Zosyn. The ADON talked to the son and the patient did not have an allergy to penicillin, just a history of blood clots. There is a letter from the daughter, who wrote in a letter that the patient was quite severely allergic to penicillin. The son talked to the ADON and the only reaction to penicillin was he/she had blood clots and that was why he/she was on Coumadin (anticoagulant medication that prevents and treats blood clots). The information blood clot reaction not from Zosyn did not come from pharmacy for the ADON to tell. The physician may have felt it was not a real allergy. The Director of Pharmacy was asked about a letter from the daughter he/she mentioned. He/She heard the daughter said the resident was allergic. The Director of Pharmacy just saw penicillin allergy in the chart, but no reaction was documented. There was no documentation of anaphylaxis in the medical record for what he/she could see. The allergy showed the reaction was blood clots. Pharmacy spoke to the physician and the physician was facilitating the order. There was no documentation of contact with nursing or with the ADON. If patient had a reaction of anaphylaxis, they would not have gone forward with that order. There was no documentation of severe anaphylaxis in the medical record. The resident was treated for anaphylaxis in the hospital and he/she had sepsis. The physician contacted the pharmacy to order it and the physician talked to the nurse. That was what they were told. Blood clots is what pharmacy was told the son said. It came from the ADON, but he/she but did not see it in the pharmacy records. He/She said it was what he/she was just told. During an interview on [DATE] at 2:48 P.M., the Administrator and Director of Nursing (DON) said they were here at the time the resident was admitted and were aware he/she went out to the hospital. The DON said he/she had allergies listed and the son talked to the nurse and they reported there was an allergy to it and the resident got blood clots. Blood clots was not an allergic reaction. The Administrator said Physician A was aware the son made a statement about penicillin causing blood clots. The information was from the nurse to the doctor. Physician A ordered the Zosyn because it was not a true side effect of penicillin and there was only a few antibiotics he/she could use. The son believed the resident was on blood thinner because of the allergy, but it was atrial fibrillation. The DON said when an order is entered, they have to click a button if physician is aware of the order, press if they want to continue to order or if the physician approved or not. The DON said she was here and the son did not say it could kill him/her. There was no other reaction other than blood clots. The DON was there when the IV or the peripheral was placed. The DON was not at the facility during the resident's change in condition. The son was hopeful and grateful because resident was combative and total care. The son did not want the resident to go out to the hospital. Allergies are located in the allergies tab in the medical record. The allergy to penicillin was documented, but no reaction was documented. Some residents cannot say what the reaction is, but they do inquire about allergies, even food allergies, before it is administered. The Administrator and DON only knew about contact with the son, no other family member called, sent a letter, or spoke to about allergies. The DON would have to look into the notes, but believed the nurse talked to the physician. She was certain nursing was in contact with pharmacy and the physician multiple times. It may not be documented, but the medication would not be sent over without the approvals. For antibiotics and any medication, there is an assessment, and nursing would take vitals. For antibiotics, it specifies the reason they are on it. Nursing was back in the room several times and at the half hour mark after administration. The resident had hypoxia and shortness of breath. They had been in there several times prior; they changed him/her because he/she was incontinent. The Administrator said she was sure the physician was on the phone with nursing. The order should not come over without physician approvals. If Physician A is not on the phone, he is electronically communicating with staff. The Administrator said they may not have policies requested by the surveyor for physician orders, IV medication administration, and change in condition. The DON said she will look for them. During an interview on [DATE] at 3:15 P.M., Physician A said he/she believed the pharmacy called to inform him/her the urine culture showed different bacteria. The cultures were looked at and Zosyn was recommended. Physician A wanted to review the record and call back. At 4:45 P.M., Physician A called back. The resident was confused and he/she had a UTI. He/She was on Macrobid. The pharmacy called and said it was MDRO and there was greater than 100,000 from the culture from [DATE]th, and was resistant other than Zosyn. He/She called the pharmacy to guide him/her. The other option that left was Zosyn. He/She went into sepsis due to UTI and was resistant to all medications. The only option left was Zosyn because he/she became septic. The order came from pharmacy. The information regarding allergies to blood clots was not clear on the penicillin allergy. Everything else was resistant in the urine culture. All 12 antibiotics were resistant to the bacteria. There was no discussion regarding resident being highly allergic or it could kill him/her. Anaphylaxis was not mentioned. The resident was also confused. It was one of the concerns. If the UTI was not treated, they have to consider hospital re-admission. They wanted to treat the UTI because it was sensitive. Physician A would not administer Zosyn if it was relayed the resident was highly allergic and it could kill him/her. Sometimes someone says they are allergic from [AGE] years ago. A lot of people say they are allergic and penicillin caused a rash. Labeling yourself allergic to penicillin, you are not able to take a lot of medications. If they stated blood clots, that is a mild allergy. It is unusual to have a blood clot allergy to penicillin. The resident was to treat the Citrobacter on [DATE]th. This is MDRO on the lab. Physician A asked pharmacy, and they said the only option was IV Zosyn. There was complete understanding he/she was on Macrobid and he/she was really confused. The fear was the resident not responding and he/she would go into sepsis. During an interview on [DATE] at 3:25 P.M., the resident's son said he did not remember the nurse's name he spoke to. He/She just stuck his/her head in the room. The phone was on his/her shoulder. He/She asked why did he/she have penicillin on the allergy list. He told him/her that it caused blood clots, he/she was highly allergic and that it could kill him/her. It had been on his/her list for 30 or [AGE] years. They updated it 2017 at the hospital. Apparently that was not listed on the reactions. The son left the facility at 6:30 P.M., they called him and and resident was sent to the emergency room at 11:00 P.M. The resident was gasping for air, they came in, and gave him/her a breathing treatment in the emergency room . They would not let the son in when he got there. There were two nurses and doctor in there. They said the resident was in critical condition. Penicillin allergy is on his/her list and they gave it to him/her anyway. They know they messed up and now he/she is on hospice and now his/her heart is damaged on one side. That was the indication he got from the doctor. It was a result of the Zosyn. The son said years ago, the resident had a blood clot and he/she was slumped over in the car. His/Her spouse thought he/she had the flu, so he/she gave the resident a penicillin capsule. He/She started having a reaction, so they drove to a car dealership, and they called EMS and took him/her to hospital. That was when they found out he/she was allergic to penicillin. That was [AGE] years ago. He/She had numerous venous thrombosis in the legs in his/her history. He/She had pin sized blood clots in the past. Anything with penicillin should be kept away from him/her. If there's bacteria, the physician has to be careful of what he/she prescribes. He/She is incapacitated now and is on hospice. The resident still had a UTI at the new facility and even at the hospital. At 3:43 P.M., the son called back and said someone from the hospital or the facility called him in the past and they said they did nothing wrong and he told the nurse it caused blood clots. The son confirmed in addition to blood clots, highly allergic and it could kill him/her were communicated to the nurse. During an interview on [DATE] at 4:00 P.M. the DON said the part of it could kill him/her meant the blood clots. The son was asked what the reaction would be, and he said it would cause blood clots. The resident was started on Eliquis (blood thinner) due to atrial fibrillation. He was asked if it was blood clots and he said I am not medical and that is the only reaction he knew he/she had. Once the resident was discharged from hospital, his/her son did not want him/her to come back. The day the resident received the Zosyn, it was an all day ordeal. He/She was demented and combative. The son thought sending him/her out would cause more confusion. The son told the resident, they have to stick you, they have an IV. They got the IV placed and re-visited back and forth with the pharmacy and doctor. It was never mentioned any amount of penicillin was lethal. The Administrator said the physician made the decision and there were limited antibiotics. There was no documentation of anaphylaxis and no shortness of breath. They did explore every opportunity of what happens with penicillin. The statement made tried to kill him/her that was when they were discharge planning at the hospital. They spoke to the physician who approved the medication. The son was aware and was okay with the medication. The physician was aware of the blood clots. Everything was a team effort. The son was aware Zosyn was administered, and convinced resident to take it. The DON was asked if the information was documented. The DON said all the documentation goes back to the order. There is a lot to do and select different options. She would have to check if there is documentation. If anything was refused, they would have documented it. They talked to the son and patient, and documented they inserted the IV and it is a task that pops up in the record. They document by exception. The Administrator said either pharmacy called the facility or they called pharmacy. Once the order goes to pharmacy, if they see an allergy, they will call. There is a safety there that would go through the pharmacist. She did not recall if the resident was administered other medications. The son was adamant about wanting the IV medications. She believed the son's take was he would convince him/her to take the IV and they could coordinate to give it when the son was here. The son thought it would be quicker and more effective. When the resident was admitted , he/she was already total care and the son was living in an imaginary world. The resident's insurance did not believe he/she was able to stay for rehab stay because he/she would not get better. He/She did not have the potential to improve from a rehab stay. His/Her condition was already poor so there was no other chance of improvement. During an interview on [DATE] at 4:39 P.M., the DON provided documentation from social service notes. The son did not mention it could kill him/her, but the social worker notes showed the son said the facility tried to kill resident. During an interview on [DATE] at 4:39 P.M., the ADON returned with the DON and Administrator. The ADON said he/she should have slowed down during the initial interview. If the son said it could kill him/her, it would have been in his/her note. The ADON said there was a lot of mentioning of it could kill him/her from the son, but it was after the resident received Zosyn. The Administrator said the they could have killed him/her part that was said by the son was not related to the blood clots. It was after what occurred when the penicillin was administered. The Administrator said they did not see it as a medication error. It was cleared by the pharmacist. They did not make a medication error. If the son said it almost killed him/her, they would have asked more questions. MO00240500

Based upon document review and interview, the facility failed to ensure staff were trained in required infection control practices such as enhanced barrier protection (EBP) and/or other isolation precautions. The facility failed to have staff's competencies in relation to the infection control training. This failure placed all 80 residents at risk of infection. The lack of adequate training and evaluation of staff's competencies had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility. Findings include: Review of the course printouts for available education on the computer-based system provided by the facility revealed the Annual Mandatory Courses list indicated Bloodborne Pathogens as the only infection control related education. The Course and Curriculum Assignments by Group: Surrey Place . for different disciplines lists indicated Targeted COVID-19 Training as the only infection control related education. Review of Registered Nurse (RN)1's, RN3's, and Licensed Practical Nurse (LPN)3's Progress Report for completed education for date ranges 02/25/23 through 07/31/24, 02/13/23 through 07/31/24 and 12/21/22 through 07/31/24 respectively, provided by the facility, indicated 2023-2024 Influenza Training, Bloodborne Pathogens, Hand Hygiene, and Targeted COVID-19 Training as the only infection control related education completed. Review of RN2's education, provided by the facility, indicated Infection Preventionist Basic Bootcamp for Long Term Care Facilities dated March 2019 as the only infection prevention education completed. Review of Certified Nursing Assistant (CNA)6, CNA7, CNA8, CNA9, and CNA10, education related to training/testing of infection control requirements, provided by the facility, revealed no documented training or competency testing related to infection control such as EBP or isolation precautions. The New Employee Orientation checklist from each file listed Hand Hygiene & Infection Control as checked off education, but the corresponding detailed information was not contained in the file. Interview on 07/31/24 at 1:50 PM, the Administrator stated the facility did not have a staff educator. The Administrator stated required training is given to the facility from the main hospital and it is up to facility management to make sure new training and other education is disseminated to the staff. On 08/01/24 at 9:05 AM, the Administrator was asked for policies related to training of staff and determining staff's competencies, however, no policies were provided Interview on 08/01/24 at 10:45 AM, the Director of Nursing (DON) stated that the Assistant Director of Nursing (ADON) began teaching the current IP however, neither of them, DON or ADON, were fully trained to be an Infection Preventionist. During an interview on 07/31/24 at 2:45PM, the Administrator stated that she had received CMS guidance regarding EBP and had reviewed this information with the staff earlier this year. The Administrator was unable to provide documentation that staff had received EBP training. (Refer to F880)

Based on observation, interview, review job description, and facility policy review, the facility failed to ensure one of one dietary freezer, and three of three nourishment room (Alpine Park, Canyon Creek, and Dakota) refrigerators had all food labeled, dated and was free of dirt and sticky shelves. This failure has the potential to create the environment for food-borne illnesses to occur throughout the population of 80 residents. Findings include: Observation and interview on [DATE] at 9:34 AM, on the shelves in the dietary department walk-in freezer revealed an unsealed bag in a box of frozen fish, an unsealed bag of hashbrowns, and an unsealed bag of potato wedges. The Food Service Director (FSD) stated the bags should not be left opened and the bags should be labeled with the opened date after using them. Observation and interview with the FSD on [DATE] at 8:46 AM of the shelves of the refrigerator on the Alpine Park Unit revealed the following food items not labeled or dated: There was a three-compartment to-go container of meat and vegetables, a to-go container of broccoli cheddar soup, a glass container of oriental dumplings, and a plastic bowl of watermelon with no label and/or date. The FSD confirmed the above observations and confirmed the food in the refrigerators should be labeled and dated. Observation and interview with the FSD on [DATE] at 8:58 AM of the refrigerator on the Canyon Creek Unit revealed the following food items not labeled, dated, and/or expired: There was one-half of a tuna sandwich wrapped in parchment paper, a to-go container of spaghetti with red sauce, a to-go container of rice, a to-go container of cake, a plastic container of a thick white substance, a plastic container of salsa, a to-go container of meat and cheese, and a to-go container of watermelon with no label and/or date. There was a to-go container of fruit that expired on [DATE], a parfait that expired on [DATE], and a to-go container of soup that expired on [DATE]. The refrigerator was observed to have dirty/sticky shelves. The FSD confirmed the above observations and confirmed the food in the refrigerators should be labeled, dated and food with expiration dates should be thrown out. Observation and interview with the FSD on [DATE] at 9:10 AM of the refrigerator on the Dakota Unit revealed the following food items as not labeled, dated, and/or expired: 3. There were two containers of potato salad, a plastic container of corn, and three-compartment to-go container of fruit all with no label and/or date. There was a container of Greek yogurt that expired on [DATE] and a to-go container of fruit that expired on [DATE]. The refrigerator was observed to have dirty/sticky shelves. The FSD confirmed the above observations and confirmed the food in the refrigerators should be labeled, dated and food with expiration dates should be thrown out. Review of the facility's policy titled, Food Safety Requirement: Procurement, Use, and Storage of Foods and Beverages in the Kitchenettes revised ,d+[DATE], provided by the facility, revealed it is the purpose of the facility, To follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness; To provide safe and sanitary storage, handling, and consumption of food and fluids brought to residents by family or other visitors .expiration date of 3 days later by nursing staff or other qualified Surrey Place employee. Food is to be removed after 2 days due to unknown conditions prior to being placed in the refrigerator or freezer. Bulk, brick-pack juices or other beverages will be dated with Date opened and Expiration Date, which is 7 days later. Review of the undated Food & Nutrition Serv-Surrey Manager [FSD] job description, provided by the facility, revealed it is the responsibility of the FSD to coordinate with other departments to plan, direct and control aspects of the Food & Nutrition Departments activities. The FSD oversees . storage .to ensure quality .to increase patient satisfaction.

Based on record review, interview and policy review, the facility failed to conduct and document a comprehensive Facility-wide Assessment to determine what resources were necessary to care for its residents competently during day-to-day operations. The facility failed to ensure the Facility Assessment included infection control services, such as surveillance and antibiotic use, as well as the facility employing an Infection Preventionist (IP) who would was responsible for overseeing the infection control program. The lack of an adequate facility assessment had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility to competently care for all 80 residents who resided at the facility. at the time of the survey. Findings include: Review of the undated Facility-wide Self-Assessment, provided supplied by the facility indicated the assessment failed to address the following pertinent characteristics affecting day-to-day operations and potential emergency situations: 1. Failed to include staffing requirements based on resident acuity levels. 2. Failed to include an evaluation of the training program, including the specialized training and competencies of the staff who worked in the facility, such as the IP and other clinical specialties/services routinely provided for the residents. (Refer to F726) 3. Failed to include infection control services, such as surveillance and antibiotic use, as well as the facility employing an Infection Preventionist (IP) who was responsible for overseeing the infection control program. (Refer to F882) 4. Failed to ensure the IP had sufficient time to assess, develop, implement, monitor, and manage the facility's Infection Prevention and Control Program (IPCP). (Refer to F882) During an interview on 07/25/24 at 10:45 AM, the Administrator confirmed the Facility Assessment did not address staffing requirements based on resident acuity levels, the assessment did not address an evaluation of the facility's training program and provide infection control services overseen by the IP. During an interview on 08/01/24 at 2:23 PM, the Administrator was asked specifically why the infection control program was not included in the Facility Assessment and why there was no mention of the IP. The Administrator stated she has not seen other examples of a written Facility Assessment mention that they provide infection control surveillance and employ an IP to oversee the program. 46592

Based on interview, document review, and policy review, the facility failed to ensure the Infection Preventionist (IP) attended the quarterly Quality Assurance and Performance Improvement (QAPI) meeting. This failure had the potential to affect all 80 residents who reside in the facility and an application of infection control prevention measures to be evaluated. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) dated 01/19 indicated, .These are the steps that Surrey Place is implementing to be compliant with the CMS QAPI regulations .QAPI will be held quarterly, and the following individuals or designee will be invited to attend.Executive Director.Medical Director.DON (Director of Nursing).ADON (Assistant Director of Nursing).Admission Director.Department Managers.MDS (Minimum Data Set) Coordinators.Clinical Educator.Medical Records Supervisor.Social Services.Registered Dietician.Applicable staff members.Areas of consideration for QAPI will be determined by State survey results, feedback from residents and staff, adverse events, and areas relating to clinical care, quality of life, resident choice, and care transitions. The facility's policy failed to identify the IP was to participate in the quarterly QAPI meetings. Review of documents titled Quality Assurance Performance Improvement Member Attendance for the following dates 01/10/24, 04/17/24, and 07/10/24 failed to indicate the IP participated in the quarterly QAPI meetings. Review of an undated facility job description titled Infection Prevention indicated the IP was to .to serve on, participate and attend.Quality Assurance and Performance Improvement (QAPI) Committee. During an interview on 07/30/24 at 1:05 PM, the Administrator confirmed the current IP had not attended any of the recent quarterly QAPI meetings.

Based on observation, interview, record review, the facility failed to ensure two of three medication carts (Alpine unit and Canyon unit), and one of two treatment carts (Alpine unit) were locked and secured on three of three resident halls. This failure created a risk of medications being misappropriated or tampered with. Also, the facility failed to remove expired blood collection tubes from two of the three medication rooms (Alpine unit and Dakota Bluffs unit). Findings include: 1. On 07/30/24 at 2:15PM, observation of the Alpine unit medication room revealed the following: 31 of 31 BD vacutainer blood collection tubes with expiration date on 01/31/24. Three of 13 Kangaroo Epump Enplus Spike with Flush Bag (used for nutritional feeding) with expiration dates of 01/31/24 and 05/31/24 Interview on 07/30/24 at 2:31 PM, Licensed Practical Nurse (LPN) 4 stated that she was not sure who was responsible for removing expired medications and equipment from the medication room. 2. Observation on 07/30/24 at 2:29 PM, on the Alpine unit was an unlocked treatment cart at the nurse station. The cart was unattended by nursing staff. On 07/30/24 at 2:40 PM, the treatment cart remained unlocked and was brought to the attention of LPN 4, who stated that she was the last one to use the treatment cart and thought she had locked it. LPN4 stated it was hazardous to leave the cart unlocked since it contained wound supplies which could be dangerous if ingested. 3. On 07/30/24 at 3:31PM an inspection of the Dakota Bluffs unit medication storage room revealed the following: Seven of eight Magellan three milliliter(ml) syringes with hypodermic needles size 21 gauge by one and a half needle had an expiration date of 10/31/23. Five of 10 Magellan three ml syringes with hypodermic safety needle size 25 gauge by five eighth inch with an expiration date of 09/30/22. Three hundred and eighty-eight lavender top BD vacutainer blood collection tubes with expired date of 04/30/24. During an interview on 07/30/24 at 3:25 PM, LPN 3 confirmed the expired dates on the syringes and the vacutainer collection tubes. LPN3 stated that she was unsure as to who was responsible for checking the medication storage room. 4. Observation on 07/30/24 at 3:45PM, the Alpine unit medication cart was left unlocked while nurse gave medication to a resident at the nurse station. Certified Medication Technician (CMT)'s back was turned away from the cart. She returned to the cart 2.35 minute later and locked the cart. An interview 07/30/24 at 3:50PM, CMT1 stated she did not realize that she left the cart unlocked. 5. Observation on 07/31/24 at 8:50 AM, Registered Nurse (RN)2 left the medication cart unlocked on the Canyon Creek Hall. Interview on 07/31/24 at 9:05 AM, RN2 stated that she was unaware that she left the cart unlocked. 6. Observation on 07/31/24 at 5:15 PM, the treatment cart was unlocked at the Dakota Bluff Hall nurses station. There were one cognitively impaired residents seated around the nurses station. There were no staff present at the station to supervise the residents. Review of Resident (R)24's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/24 revealed a Brief Interview for Mental Status (BIMS) revealed R24 was severely cognitively impaired and unable to complete the BIMS. Interview on 7/31/24 at 5:20PM, LPN 3 stated that it was an expectation that all medication and treatment carts were to be kept locked. Interview with the Director of Nursing (DON) on 07/31/24 at 11:30AM, the DON stated that the nurses are expected to always keep the medication and treatment carts locked when not in used. The DON stated that the facility did not have policy regarding the locking of the medication and treatment carts.

Based on observations, record review, review of policies, interviews, and review of Centers for Disease Control (CDC) guidelines and Centers for Medicare & Medicaid Services (CMS) guidance, the facility failed to follow acceptable standards of practice for infection prevention and control when providing wound care for Resident #35. The facility also failed to ensure one (Resident (R)144) of one resident with a diagnosis of Methicillin-Resistant Staphylococcus Aureus (MRSA) was placed in contact precautions. This had the potential for MRSA to spread to staff and to other residents. The facility failed to ensure R1 and R36 were placed in enhanced barrier precautions (EBP) for wounds and R294, R6, R35 for use of a catheter. This had the potential for the residents to develop multi-drug resist organisms. The facility failed to ensure dedicated equipment, such as a stethoscope and blood pressure cuff, was assigned to R37 who was in contact precautions for a diagnosis of Clostridium difficile (C-diff). This had the potential for staff and other residents to develop C-diff. The facility nurses failed to perform during wound treatment for one of one resident (R1) hand hygiene prior to donning gloves and failed to change gloves and perform hand hygiene after removing the old dressing and applying the new dressing. This failure had the potential of contaminating the clean dressing. The facility failed for one of one resident (R5) with a suction machine in their room, to clean the suction machine cannister that was observed with yellowish fluid. The facility failed to ensure a diagram of the current facility's water system was developed as part of their water management program and prevention of pathogens. Finally, the facility failed to ensure four ice machines out of four were properly cleaned on a routine basis. This had the potential for the facility to develop water pathogens. The census was 79. Findings include: Review of the facility's infection control policy, dated October 2023, showed: -Policy: It is the policy that this facility's Infection Prevention and Control Program (IPCP) is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The IPCP includes a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards; -Standard and transmission-based precautions to be followed to prevent the spread of infections, including: --Hand hygiene to be followed by staff with direct care, handling resident care equipment and the environment; --Resident Care Activity procedures including wound care; --Environmental cleaning and disinfection of resident care equipment, including shared equipment. 1. Review of Resident #35's admission sheet, showed the resident was admitted to the facility on [DATE] with diagnoses that included severe malnutrition, failure to thrive, chronic obstructive pulmonary disorder (COPD, a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and a history of falls. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/8/24, showed: -Cognitively intact; -Required partial to moderate assistance with eating, personal hygiene and upper body dressing; -Dependent on staff for toileting, bathing, transfers, putting on/taking off shoes and lower body dressing; -Used a wheelchair. Review of the resident's electronic Physician's Orders, showed: -7/20/24, Cleanse resident's right leg wound with wound cleanser, apply triple antibiotic ointment (TAO) then apply 4 inches by 4 inches gauze, wrap in Kling wrap (rolled gauze dressing) and secure with tape. No tape to the skin. Observation of the resident's right lower leg dressing change on 7/24/24 at 5:30 P.M., showed: -Registered Nurse (RN) A rolled the Canyon Creek (hall resident resided on) treatment cart #2 to the resident's room and positioned it in front of the doorway; -RN A explained to resident what he/she was going to do; -RN A exited the room; -RN A entered the room with a pillow and bedding pad; -RN A folded the pillow and placed it under the resident's right lower leg, then folded the pad in half and placed it on top of the pillow. RN A then placed the resident's right leg on top of the pillow and pad; -RN A used hand sanitizer on his/her hands, donned gloves and began to gather supplies onto the top of treatment cart #2 without the use of a barrier or disinfecting the top of the cart; -RN A removed his/her scissors out of his/her pocket and placed the unsanitized scissors on top of the unsanitized cart; -RN A gathered the supplies off the top of the unsanitized cart and placed them on to the right side of the pad and the scissors onto the right side of the pad; -RN A used the scissors, cut open the visibly soiled dressing to the resident's right leg and placed the used scissors back onto the right side of the pad; -RN A cleansed the wound with wound cleanser and 4 by 4 gauze, then removed the soiled dressing from beneath the resident's leg and disposed of the dressing and gauze in the trash on the treatment cart; -RN A doffed his/her gloves, used sanitizer on his/her hands and donned new gloves; -RN A opened the gauze 4 by 4 and placed on the left side of the pad, opened the cotton tipped applicator and placed it on the left side of the pad; -RN A opened the antibiotic ointment and applied some to the cotton swab and then applied it to the wound, added more ointment and applied to other areas of the wound three times, placed the open and used ointment package on the right side of the pad; -RN A placed the gauze 4 by 4 on the wound and then walked to the treatment cart in the open doorway; -RN A removed the rolled gauze from the cart and placed it, open, on the right side of the pad; -RN A wrapped the rolled gauze around the leg/wound, grabbed the dirty scissors off the pad and cut the clean rolled gauze with the dirty scissors; -RN A gathered the trash and supplies, threw away the supplies and placed the used bottle of wound cleanser in the cart and the used/dirty scissors on the cart top without a barrier; -RN A doffed his/her gloves, sanitized his/her hands and donned clean gloves; -RN A removed the tape from the drawer of the cart, used a marker and initialed and dated the tape, and removed two pieces of tape; -RN A taped the rolled gauze in two areas to make sure it was secure; -RN A removed the pad and pillow from under the resident's leg and placed them in the dirty bin in the hallway; -RN A placed the cart in the hallway and returned to the resident's room to assist the resident with covering up and adjusting his/her position in bed; -RN A exited the room, doffed his/her gloves, sanitized hands and pushed the treatment cart to the nurse's station; -RN A gathered two packages of cookies and took them to resident per resident request; -RN A walked back to the treatment cart and placed his/her dirty scissors and marker inside a glove, twisted it closed and walked away from the cart leaving the glove sitting on top. During an interview on 7/24/24 at 5:53 P.M., RN A said: -He/she usually used foam sanitizer instead of washing his/her hands; -Hands should be washed between glove changes and before exiting the resident's room after the treatment; -He/she did not wash his/her hands with soap and water at any point before, during and after wound care; -He/she got used to using the foam sanitizer so that is what he/she does; -If the resident had C-diff, he/she would always wash his/her hands with soap and water before exiting the room; -He/she usually washes his/her scissors and marker outside the resident's room and lets them air dry on top of the cart, then places them back into his/her pocket; -He/she placed the scissors and marker inside the glove to remind himself/herself that they still need to be cleaned before placing them back into his/her pocket; -Do not need a barrier for the top of the cart; -He/She will use a bed pad for a barrier, open the supplies and set them on the bed pad; -If the bed pad gets soiled, he/she would change the pad after cleansing the wound and before adding a clean dressing; -Sometimes, he/she will either place two pads under the wound and remove the top one after cleansing the wound or just keep folding the soiled pad as needed. During an interview on 7/24/24 at 6:05 P.M., the Director of Nursing (DON) said: -He/she expected staff to wash hands when entering a room to provide care, if the gloves get soiled, and after care is completed; -Hand sanitizer is ok to use instead of washing hands with soap and water as long as the hands are not visibly soiled; -He/she expected staff to use soap and water if the resident has C-diff; -Staff does not need to use a barrier if they have a clean surface; -As long as the supplies are in individual packaging, a barrier or cleaning the top of the cart is not required before placing the packaging on top of the cart; -He/she expected staff to sanitize scissors before and after use; -Sanitizing the scissors after removing the dressing and before using them on clean supplies is not required if it is the same resident; -It is ok to use the same pad for clean and dirty items as long as the clean items and the dirty items are placed in separate areas of the pad; -It is not acceptable to place clean items with dirty items. 2. Review of the Resident (R) 144's electronic medical records (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included septic arthritis and swollen right knee. Review of the R144's EMR document titled Resident Summary Sheet indicated while in the hospital, due to blood cultures and synovial fluid on 07/19/24 and nasal culture dated 07/21/24 tested positive for MRSA. Review of R144's Physician Orders dated 07/23/24 provided by the facility revealed the resident was to receive Vancomycin (antibiotic), 1,750 milligrams (mg) in 517.5 milliliters (ml) intravenous (IV, a soft, flexible tube placed inside a vein, usually in the hand or arm) every 12 hours for bone/joint infections. Observation on 07/29/24 at 10:30AM revealed R144 in his room in bed with a dressing covering the right knee area. There was no signage or Personal Protective Equipment (PPE) cart outside the resident's room. Observation on 07/30/24 at 3:30 PM revealed R144 in his room and no PPE setup outside the resident's room. The resident's right knee dressing was changed on 07/30/24. Observation on 07/31/24 at 8:10 AM revealed no PPE setup or signage posted outside R144's room. Interview with R144 during this observation revealed the nurses wore gloves when doing dressing changes. R144 was not sure if the nurses wore gloves when hanging his IV medication. The resident further stated the staff do not wear a gown or gloves when providing his care. Observation on 07/31/24 at 8:33AM revealed Certified Nurse Aide (CNA) 5 was observed exiting R144's room after taking his vital signs. The CNA was not wearing any PPE, nor did she disinfect the blood pressure apparatus. Interview on 07/31/24 at 8:40 AM, CNA 5 stated she received infection control training (isolation precautions) during orientation. CNA5 stated that if a resident is in isolation precautions there will be signage on the door identifying what personal protective equipment is required and there will be a cart outside the resident's room with the PPE. The CNA also stated staff should wear gowns, masks, and gloves and practice hand sanitation for residents in isolation. The CNA was unfamiliar with EBP. Interview on 07/31/24 at 9:26 AM, RN 2 on the Canyon Creek Hall team 1-2 revealed only one resident was on isolation precautions. The resident was admitted to the facility yesterday and tested positive for COVID. RN2 stated the resident was in contact isolation which required staff to perform hand hygiene, don an N95 face mask, gown, and gloves. RN2 further stated there were no residents on EBP at this time. RN2 stated that the required PPE for residents on EBP would be face mask and face shield, if the employee desired face shield, and gloves. RN2 stated in her unit she had several residents with wounds and indwelling (drainage tube inserted into the urethra)/suprapubic (drainage tube inserted into the abdomen) catheters. Interview on 07/31/24 at 9:39 AM, RN1 on the Canyon Creek Hall Team 2-3 stated that she did not have any residents on any type of isolation precautions. RN1 stated the PPE for residents on contact isolation should be face mask, gowns, and gloves. The RN stated that she had never heard of EBP. RN1 acknowledged that R144 had a wound infection of the right knee but did not know what organism was growing from the wound. RN1 was asked if a resident had MRSA in a wound, would that require isolation precautions. RN1responded that the resident should be placed on Contact Isolation. Interview on 07/31/24 at 10:11 AM, the Assistant Director of Nursing (ADON) stated that she was familiar with the residents on the Canyon Creek Hall and not sure if there were any residents with the diagnosis of MRSA on the Canyon Creek Hall. The ADON stated staff providing care to residents on contact isolation should wear gowns, mask, and face shield mask to prevent splash back of resident secretions, and gloves. The ADON stated she would have read the policy for EBP. She stated that she found out this morning prior to this interview that staff were not following the EBP guidance. The ADON stated that several residents had wounds that required dressing, indwelling urinary /Suprapubic catheters and intravenous therapy. These residents were not on any type of isolation precautions. Interview on 07/31/24 at 1:10PM, CNA 5 revealed there was only one resident on the unit that was on isolation precautions. CNA 5 stated the staff should wear face mask, gown, and gloves when providing care for the resident. CNA 5 was asked what PPE was used for residents on EBP. CNA 5 responded, What's that? Interview on 07/31/24 at 02:45PM with the Administrator and the DON revealed the DON was unaware that R144's was positive for MRSA. The DON had to review the resident's chart. The DON stated that Infectious Disease physician felt that since R144 was afebrile and asymptomatic it was not necessary to place the resident in isolation. The DON was asked to review the resident's microbiology report which indicated the resident tested positive with MRSA in blood, wound, and nasal cultures on 07/19/24 and 07/21/24. The DON stated the resident's blood culture done on the 07/23/24 was negative. However, the DON was unable to answer or explain why the resident did not have repeat culture of the resident's wound and the nares. The Administrator stated that since the resident's wound was covered it would not be necessary for the resident to be in isolation. The Administrator stated she had received CMS guidance regarding EBP and had reviewed this information with the staff earlier this year. The Administrator and the DON could not explain why R144 was not placed in some type of EBP. The DON was unable to provide documentation regarding the guidance the Infectious Disease physician indicated about not placing the resident in isolation. The Administrator was unable to provide documentation that staff had received EBP training. Interview on 08/01/24 at 4:19PM, R144's physician stated that he usually takes directions from the Infection Disease physician at the hospital regarding placing residents in isolation. The Infectious Disease physician felt that since the resident was afebrile and exhibited no symptoms it was not necessary to place the resident in isolation. The Physician admitted that he was not familiar with the EBP. After reviewing CMS guidance on EBP, R144's physician agreed the resident should be placed on EBP. 3. Review of a facility policy titled Isolation Guidelines Policy dated 10/23 failed to include enhanced barrier precautions under their procedures. a. Review of a facility document titled Resident Information indicated R1 was admitted to the facility on 12/01/15. Review of R1's significant change MDS with an Assessment Reference Date (ARD) of 06/13/24 with a Brief Interview of Mental Status (BIMS) score of four out of 15 which revealed the resident was severely cognitively impaired. The MDS indicated the resident was at risk for the development of pressure ulcers and had none. Review of a facility document titled Wound Care Center Physician Note dated 07/18/24 indicated R1 had a pressure ulcer on her left ankle. In addition, the resident had a pressure ulcer on her left buttock. During an interview on 07/30/24 at 6:04 PM, Licensed Practical Nurse (LPN) 2 confirmed R1 was not on EBP and that there was no PPE available for staff to use outside of R1's room. b. Review of a facility document titled Resident Information indicated R36 was admitted to the facility on 07/19/24. Review of R36's admission MDS with an ARD of 06/20/24 indicated the resident had a BIMS score of 13 out of 15 which revealed the resident was cognitively intact. Review of a facility document titled Wound Care Center Physician Note, dated 07/25/24 indicated R36 had stage four posterior pressure ulcers with bi-lateral ankles. During an interview on 07/30/24 at 6:04 PM, LPN2 confirmed that R36 was not on EBP and that there was no available PPE outside of R36's room for staff to use. c. Review of a facility document titled Resident Information indicated R294 was admitted to the facility on 07/19/24. Review of a facility document titled Active Order Profile dated 07/19/24 indicated the resident had an order for a suprapubic catheter. Review of R294's admission MDS with an ARD of 07/25/24 indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. The MDS indicated the resident had an indwelling catheter. During an interview on 07/30/24 at 6:04 PM, LPN 2 confirmed R294 was not placed on EBP and there was no PPE available outside of R294's room for staff to use. d. Review of a facility document titled Resident Information indicated R6 was admitted to the facility on 07/17/24. Review of a facility document titled Active Order Profile dated 07/17/24 indicated R6 had an order for an indwelling urinary catheter. Review of R6's admission MDS with an ARD of 04/16/24 indicated the resident had a BIMS score of 14 out of 15 which revealed the resident was cognitively intact. The MDS indicated the resident had an indwelling urinary catheter. During an interview on 07/30/24 4:22 PM, RN2 stated R6 had an indwelling catheter and did not have any EBP in place. RN2 stated there was no PPE available for use with this resident. Observation at this time revealed there was no PPE on the outside of R6's room for staff to use. e. Review of a facility document titled Resident Information indicated R37 was admitted to the facility on 06/18/24. Review of a facility document titled Active Order Profile dated 07/07/24 indicated R37 required contact precautions due to a diagnosis of C-diff. Review of R37's admission MDS with an ARD of 06/24/24 indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. During an observation on 07/30/24 at 12:17 PM, LPN1 entered R37's room to retrieve a tissue in which the resident had spit out a vitamin that she could not swallow. LPN 1 wore gloves but no protective gown. On the outside of the resident's room was a sign titled Contact Plus and directed staff to don (put on) a gown and gloves prior to entering the resident's room. During an interview on 07/30/24 at 4:10 PM, CNA 1 stated prior to entering into the room with a resident who was under contact precautions was to don a gown and gloves. During an interview on 07/30/24 at 4:11 PM, CNA 2 stated there was no dedicated equipment, such as a stethoscope and blood pressure cuff in R37's room. During an interview on 07/30/24 at 4:15 PM, LPN 1 confirmed she did not don a gown prior to entering R37's room and that she knew the resident was in contact isolation. LPN 1 stated she did not know if R37 had dedicated equipment, such as a stethoscope and blood pressure cuff in her room. f. Review of a facility document titled Resident Information indicated R35 was admitted to the facility on 07/02/24. Review of a facility document titled LTC (Long-Term Care) All Orders dated 07/31/24 indicated the resident was ordered to have an indwelling catheter placed. Review of R35's admission MDS with an ARD of 07/08/24 indicated the resident had a BIMS score of 14 out of 15. The MDS indicated the resident had an indwelling urinary catheter. During an observation on 07/29/24 at 11:39 AM, R35's room was observed with no PPE on the outside of her room. During an interview on 07/30/24 at 4:18 AM, RN1 stated that R35 had a catheter and was not on EBP. RN1 confirmed that there was no PPE outside of R35's room for staff's use. RN 1 stated contact precautions required the donning of PPE prior to entering a resident's room, and enhanced precautions included donning PPE prior to any care contact with a resident. During an interview on 07/30/24 4:22 PM, RN2 stated R6 had an indwelling urinary catheter and did not have any EBP in place. RN2 stated there was no PPE available for use with this resident. RN2 stated R36 had bi-lateral heel pressure ulcers and had no EBP in place and no PPE available for use. RN2 stated EBP included donning PPE prior to entering into a resident room. 4. Observation of R1's wound care on 07/31/24 at 5:28 PM, revealed LPN5 performed hand hygiene before donning gloves. LPN 5 removed the dressing on R1's left ankle, then cleaned the ankle with wound cleanser. LPN5 then applied xeroform gauze to the open area and then covered the xeroform with a border dressing. LPN5 failed to perform hand hygiene and change gloves after removing the old dressing and applying the new dressing. LPN 5 then without changing her gloves moved R1's sacral wound dressing. LPN5 cleaned R1's sacral wound with the wound cleanser and applied a layer of calmoseptine ointment (moisture barrier) to the sacral area. LPN 5 never left the resident's bedside to change her gloves and perform hand hygiene. During an interview on 07/31/24 at 5:43PM, LPN 5 stated that she went in the bathroom and changed her gloves. Interview 08/01/24 at 11:30AM, the DON stated that nurse are expected to perform hand hygiene and change gloves when removing old dressings and applying new dressing for each wound. 5. Observation on 07/29/24 at 12:10 PM and on 07/30/24 at 8:45 AM of R5's room revealed a suction machine in the corner of the room on the floor. The machine had the disposable canister still in the holder and attached by the hoses. The canister contained 290 ml of yellowish fluid. Interview on 07/31/24 at 12:20 PM, RN2 stated she had not known R5 to use the suction machine for some time, but the machine remained in his room for an emergency related to his condition. RN2 stated she had noticed the machine on the floor earlier but did not notice that the canister had fluids in it. RN2 stated the practice is to leave all respiratory machines on a table and not the floor, to empty the canister as needed and clean the machine after use and/or for storing. Interview on 08/01/24 at 9:28 AM the DON stated R5 came with the suction machine but had not used it for a long time. The DON stated the machine should not have been placed on the floor for any reason, the machine should have had the canister cleaned or thrown away and the entire machine cleaned as well. 6. Review of a facility undated policy titled, Water Management Policy and Procedures Indicated, . It is the intent of this facility to implement a water management program that will inhibit microbial growth in building water systems and to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. Review of the CDC website titled Legionella. Prevention and Control, dated 03/25/21, indicated, The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella.Key Elements.Seven key elements of a Legionella water management program are to. Establish a water management program team. Describe the building water systems using text and flow diagrams. Identify areas where Legionella could grow and spread. Decide where control measures should be applied and how to monitor them. Establish ways to intervene when control limits are not met. Make sure the program is running as designed (verification) and is effective (validation). During an interview conducted on 07/30/24 10:16 AM, the DON stated there were no Legionnaires in the facility. During an interview on 07/31/24 at 3:36 PM, the Maintenance Director (MD) verified there was no water diagram of the facility's water system. 7. Observation and interview on 07/30/24 at 10:25 AM revealed the kitchen's ice machine to have an orange-colored substance and a dark gray substance on the outside portion of the see-through ice dispenser. The Food Service Director (FSD) stated there should not be any colored substances on the spout and that the ice machine was not clean. Observation and interview with the FSD on 07/31/24 at 8:46 AM of the ice/water machine on the Alpine Park Unit revealed the machine to have a white crusty material on the water dispensing area and the grate by the drain. The FSD confirmed the machine was not clean. Observation and interview with the FSD on 07/31/24 at 8:58 AM of the ice/water machine on the Canyon Creek Unit revealed the machine to have a white crusty material on the water dispensing area and the grate by the drain. The FSD confirmed the machine was not clean. Observation and interview with the FSD on 07/31/24 at 9:10 AM of the ice/water machine on the Dakota Unit revealed the machine to have a white crusty material on the water dispensing area and the grate by the drain. The FSD confirmed the machine was not clean. On 07/30/24 and 07/31/24 the FSD was asked for a policy on the maintaining and cleaning of the ice/water machine. A policy was not provided. Interview on 07/31/24 at 4:27 PM, the MD stated that the facility has a company that comes every quarter to take the ice machines apart and thoroughly clean them. The MD stated housekeeping was responsible for cleaning the ice machines between quarterly cleanings. The MD stated there is no documentation that indicates the ice/water machines were cleaned by housekeeping. 16752 34926 46592

Based on observation, interview, record review, and facility policy review, the facility failed to assess one of one sampled resident (Resident (R) 37) for the safe self-administration of medications. This failure could potentially lead to medications being left by staff at the resident's bedside where other residents could access them. Findings include: Review of the facility's policy titled Self-Administration of Medications Policy dated 10/23 indicated, .It is the policy of this facility that if a resident requests to self-administer medication(s), the interdisciplinary team (IDT) will assess the resident to determine if it is clinically appropriate to honor the resident's choice, in order to maintain the resident's highest practicable level of functioning. The resident has the right to defer responsibility to the facility. A resident may only self-administer medications after the IDT has determined which medications may be safely self-administered. Review of a facility document titled Resident Information indicated R37 was admitted to the facility on [DATE]. Review of R37's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident had a history of choking during meals or when swallowing medications. Review of R37'sCare Plan failed to indicate the facility assessed the resident for safe self-administer of her medications. Review of R37's electronic medical record (EMR) failed to show evidence the facility assessed the resident for the safe self-administration of her medications. During an interview on 07/30/24 at 12:17 PM, R37 stated she no longer required skilled Speech Therapy and could identify when she needed to pull food from her mouth if she began to pocket the food. During this interview, Licensed Practical Nurse (LPN) 2 entered into the resident's room and the resident informed LPN 2 that she could not swallow the vitamin and asked if LPN2 could crush the vitamin. The resident pointed to a crumbled-up tissue with a slight orange spot in the middle of it. LPN2 retrieved the tissue and said that she would do that for the resident. During an interview on 07/30/24 at 12:19 PM, R37 stated LPN 2 left a Tylenol and a Vitamin at her bedside for her to take by herself. The resident stated LPN2 was not present when she took her pills. During an interview on 07/30/24 at 4:15 PM, LPN 2 confirmed she left the vitamin and Tylenol at R37's bedside and alone. During an interview on 08/01/24 at 1:14 PM, the Director of Nursing (DON) stated R37 wanted the medications left at her bedside and the facility was honoring her choice. The DON stated that residents should not be unsupervised, with medications, unless the facility previously assessed the resident for the safe self-administration of medications.

Based on interview and record review, the facility failed to protect one resident (Resident #38) from misappropriation of property when a staff member took the resident's wallet, and used his/her credit card to purchase take-out food and groceries. The census was 79. The administrator was notified on 7/24/24 of the past non-compliance. The facility had completed their investigation, interviewed staff and residents, notified the police and terminated Certified Nurse Aide (CNA) A. The deficiency was corrected on 7/24/24. Review of the Abuse and Neglect (Suspected) Policy, revised March 2022, included the following: -Residents have the right to be free from any type of abuse, including verbal, physical, psychological, sexual, and emotional abuse and/or exploitation; -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of Resident #38's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/24, showed the following: -Cognitively intact; -No behaviors; -Diagnoses included high blood pressure, diabetes, total knee replacement; -Hearing and vision adequate; -Understands others. Review of the facility's investigation, submitted 7/16/24, showed the following: -The resident said a couple of nights before, he/she had CNA A help read the card verification value (CVV) on the back of his/her credit card and the CNA returned the card. He/She wanted the wallet returned and did not want to file charges; -A Timeline of Events for July 12, 2024, created by the Director of Nursing (DON); -Separation of employment completed for CNA A. During an interview on 7/24/27 at 11:10 A.M., the resident said he/she was shopping one night and could not read the CVV on the back of the credit card. He/She asked the AP to help him/her read the number. The CNA went to get his/her glasses, came back and read the number and returned the wallet to the resident. The resident placed the wallet near the head of the bed. On 7/12/24, he/she could not recall the exact time, he/she received a call regarding fraudulent charges on his/her credit card. The resident reviewed the online banking information and noted the charges at a grocery store and a food restaurant. That is when he/she first noticed his/her wallet was missing. The DON and Nurse Supervisor (NS) came to the resident's room, gathered information and the NS assisted the resident in calling the credit card company to get the times of the transactions. The NS called the restaurant and was given a description of the person who used the card to purchase food. During an interview on 7/24/24 at 11:20 A.M., the DON said he/she was present in the facility the day of the incident. At approximately 2:55 P.M., she was notified by an employee the resident reported he/she was missing a wallet and there were charges on his/her credit cards. The DON and NS went immediately to the resident's room. The resident said a couple of nights before, he/she had the CNA help him/her read the CVV on the back of the credit card and the CNA returned the card. The resident did not realize his/her wallet was missing until the bank fraud department contacted him/her for some charges that occurred on 7/12/24. The resident reviewed his/her account and was unable to locate the wallet, and the resident notified a staff member. After gathering the information, the NS contacted the local police department and requested an officer to come make a report. The DON reviewed the staffing sheets and noted the CNA was scheduled for that evening but was running late. When the CNA arrived, carrying a plain white bag with food items, he/she was directed to complete education on the computer in the part of the building with no resident contact. The Police Officer arrived, took the statement from the resident, staff, and requested the CNA be brought to the conference room. The CNA confirmed he/she took the wallet and made purchases at the grocery store and restaurant. During an interview on 7/24/24 at 2:41 P.M., the NS said the resident reported the wallet as stolen. The resident got a notice from his/her bank for fraudulent charges. The NS helped the resident call the bank and get times of the charges to the card. The NS called the restaurant, where the card was used, and the staff provided a description of the person, the car, and the items ordered. When the CNA arrived to the facility, the DON instructed the AP to complete computer training in a different part of the facility, away from resident contact. The police interviewed the resident and staff. The CNA was brought to the conference room. The next time the NS saw the CNA was out front of the lobby at the police car. The DON said the CNA was arrested and the officer was waiting for a female officer. Review of the Police Department Investigative Report, showed: -A purple coin purse/wallet with twist latch was stolen. Contents included a driver's license, Costco credit card, Credit Union debit card, American Association of Retired Persons (AARP) membership card, PNC Bank Credit Card, library card, twenty-three dollars ($23.00) in cash, two un-signed blank checks; -The Alleged Perpetrator (AP) was charged with Stealing (Class D Felony)-all other property and Fraudulent Use of Credit/Debit Device. Total value $46.03; -Fraudulent charges, takeout food fifty-one dollars ($51.00) and groceries fifty-seven dollars and ninety-nine cents ($55.99); -The AP admitted to taking the wallet and was arrested. MO00239018

Based on record review and interview, the facility failed to ensure a baseline care plan (CP) that addressed specific needs was provided for three of 26 sampled residents (Resident (R)7, R294, and R297). This failure had the potential to cause staff to not receive the necessary instructions needed to provide effective care and meet the needs of residents. Findings include: 1. Review of the History and Physical Reports provided by the facility revealed R7 was admitted on [DATE] with diagnoses including chronic kidney disease and chronic lower extremity edema. Review of the Baseline Care Plan LTC initiated on 07/11/24, provided by the facility, revealed medications listed on the plan, but no indications of treatments or monitoring. The baseline CP provided by the facility had concerns related to skin integrity, but no specificity related to edema. 2. Review of the History and Physical Reports provided by the facility revealed R294 was admitted on [DATE] with diagnoses including left distal femur periprosthetic fracture, depression, and diabetes mellitus. Review of the Active Orders Profile supplied by the facility revealed R294 had orders for duloxetine (antidepressant) 30mg (milligram) per day initiated on 07/19/24. Review of the Baseline CP LTC dated 07/20/24 and supplied by the facility revealed R294 had orders listed for warfarin 4mg daily but did not have monitoring for signs and symptoms of adverse effects. Review of the Baseline CP LTC initiated on 07/19/24, provided by the facility, revealed concerns and interventions related to diabetes mellitus and antibiotic use, but no concerns/interventions related to the use of anticoagulants, such as monitoring for the signs and symptoms of bleeding, and no concerns/interventions related to the use of psychotropic medications such as antidepressants and monitoring for psychosocial issues. 3. Review of the History and Physical Reports provided by the facility, revealed R297 was admitted on [DATE] with diagnoses including a urinary tract infection. Review of the Surrey LTC - Medication Administration Record Report for the month of July 2024 and provided by the facility revealed R297 to be on an antibiotic from 07/22/24 through 07/27/24. The Administrator was asked to provide R297's baseline care plan. However, it was not received prior to the survey team exiting the facility. Interview on 08/01/24 at 9:28 AM, the Director of Nursing (DON) stated that the nurses put orders into the system and do a baseline CP from there. The MDS department then receives reports to put more resident oriented care plans in place. The DON stated all specialized treatments and mediations should be included on the baseline CP. Interview on 08/01/24 at 2:35 PM, the Minimum Data Set (MDS) Coordinator (MDSC)3 stated all medications (antidepressants, anticoagulants and antibiotics) should be included on the base line CP.

Based on interview and record review, the facility failed to ensure residents were free from significant medication error after one resident with an allergy to penicillin (a class of antibiotics that are commonly used to treat bacterial infections) was ordered and administered Zosyn (a penicillin antibiotic used to treat infections) intravenously (IV, into the vein) to treat a urinary tract infection (UTI) (Resident #503). The facility failed to get a detailed account of the resident's reaction to penicillin after it was reported and the resident's reactions were not documented in the medical record. The resident's family reported to facility staff the resident's reaction to penicillin was blood clots, he/she was highly allergic, and it could kill him/her. The nurse reported he/she was informed the resident's reaction was only blood clots. The pharmacy and the physician were informed the resident's reaction were only blood clots. The resident was administered Zosyn IV and thirty minutes later, he/she had difficulty breathing, was administered four liters of oxygen, and was transported to the emergency room. The resident was diagnosed with anaphylaxis (a severe, potentially life-threatening allergic reaction), was noted to be hypoxic (a condition that occurs when the body or part of the body does not receive enough oxygen at the tissue level) and was administered two rounds of epinephrine (adrenaline, emergency treatment for severe allergic reactions including anaphylaxis caused by unknown substances). The sample was four residents. The census was 65 with 52 in certified beds. Review of the facility's Medication Orders Policy, reviewed February 2021, showed: -Policy: Medication Orders shall be clear and accurate. Practitioners with delineated clinical privileges shall be able to give orders. Written patient medication orders for treatment shall be dated, timed and signed by the prescriber. All other medication orders will be entered into the hospital computer system via CPOE. Orders entered by a non-physician, shall be countersigned by the ordering physician; -Process for Accepting a Telephone Order: The hospital minimizes the use of verbal and telephone medication orders. Only authorized prescribers can give telephone orders; -Telephone orders are permitted. When taking a telephone order, the listener will type the order into CPOE. The listener will read the entire transcribed order back to the prescriber, including the patient's name and will use words instead of abbreviations. The prescriber will countersign the telephone order; Telephone orders are not to be taken for anti-neoplastic agents, except to discontinue or hold the antineoplastic agent. A telephone order that seems inconsistent with the patient's problem will be questioned/clarified before the order is implemented; -Preprinted and electronic standing orders, order sets, and protocols for medication orders include the following Processes for use: Review and approval of standing orders and protocols by the medical staff and the hospital's nursing and pharmacy leadership; -Evaluation of established standing orders and protocols for consistency with nationally recognized and evidence-based guidelines; -Regular review of such standing orders and protocols by the medical staff and the hospital's nursing and pharmacy leadership to determine the continuing usefulness and safety of the standing orders and protocols; -Dating, timing, and authenticating of standing orders and protocols by the ordering practitioner or another practitioner responsible for the patient's care in accordance with professional standards of practice; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations. Review of Resident #503's face sheet, showed: -admitted on [DATE]; -Admit reason: Covid positive, fever, acute urinary retention, weakness, failure to thrive, malnutrition, congestive heart failure exacerbation; -Allergies: Penicillin and Zosyn. Review of the resident's allergy list, updated 3/27/24, showed: -Penicillin: Reaction: anaphylaxis; -Zosyn: Reaction: anaphylaxis. Review of the resident's allergy list, provided by staff and received on 9/12/24, showed: -Penicillin: Reaction: Cancelled; -Updated: 2/27/17; -Source: Family; -Received: 3/25/24; -A handwritten note showed, allergy status was cancelled in 2017. It was reviewed as cancelled again on 3/25/24 because of it being listed in history once reviewed and confirmed as cancelled medication order continued/medication administered. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 3/18/24, showed: -Diagnoses included atrial fibrillation (a-fib, irregular heartbeat), heart failure, hypertension (HTN, high blood pressure), benign prostate hyperplasia (BPH, a non-cancerous enlargement of the prostate gland), hyperlipidemia (abnormally high levels of lipids or fats in the blood), dementia, malnutrition and anxiety; -Severe cognitive impairment; -Has physical behaviors; -Incontinent of bowel and bladder; -Administered anticoagulant (medication that reduces blood clots), antibiotic and anti-anxiety medications. Review of the resident's care plan, initiated 3/25/24, showed: -Plan: Long term care genitourinary (urinary and genital organs) Interdisciplinary Plan of Care (IPOC); -Intervention: Monitor symptoms of UTI (voiding pain, mental status change) and notify nurse if present; -Note urine color, clarity, amount, odor; -Promote optimal fluid and nutrition intake intervention: Provide perineal care (peri care, washing the genitals and anal area); -Notify physician for variations in evaluation findings. Review of the physician's progress notes, dated 3/17/24, showed: -Patient concerns: Recent UTI greater than 100,000 colony forming units (cfu)/ milliliter (ml) Citrobacter Koseri (bacteria), this is a multi-drug resistant (MDRO) that is resistant to three or more class of antibiotics. Contact precautions are required. Consider an infectious disease consult if indicated; -Impression and Plan: UTI - Citrobacter Koseri; -Plan: Start Nitrofurantoin (Macrobid, antibiotic used to treat and prevent urinary tract infections). Review of the physician progress notes, dated 3/19/24, showed: -Patient concerns: Follow up of UTI, tolerating Macrobid, gets very agitated on day to day treatments, follow up of labs; -Impression and Plan: Potassium 5.1 (normal potassium level for adults, 3.5 to 5.0) and blood urea nitrogen (BUN, measures kidney function) 44 ( normal BUN level, 8 to 23 milligrams per deciliter for adults over 60); -Lokelma (used to treat high potassium levels) 10 grams (g) by mouth x one now; -Increase oral fluids; -UTI - Citrobacter Koseri; -Plan: Start Nitrofurantoin, Lokelma x one dose. Review of the physician progress notes, dated 3/21/24, showed: -Patient concerns: Follow up of UTI, tolerating Macrobid, more calm, cooperative, no chest pain, headaches, cough, nausea, vomiting, diarrhea, fever; -Impression and Plan: UTI - Citrobacter Koseri on Macrobid; -Plan: Start Nitrofurantoin, repeat urinalysis (UA, a test that examines urine to detect and manage a range of disorders) and culture. Review of the physician progress notes, dated 3/25/24, showed: -Patient concerns: Follow up UA and culture and sensitivity (C&S), still showing white cells and bacteria, more compliant; -Impression and Plan: UTI - Citrobacter Koseri on Macrobid completed will repeat UA, still showing bacteria and white cells; -Will start him/her on Zosyn 3.375 gram (g) every 8 hours; -Plan: Will start Zosyn 3.375 every 8 hours for five days. Review of the progress notes, showed: -Service date/time: 3/25/24 at 6:00 P.M.; -Performed by Assistant Director of Nursing (ADON) on 4/12/24 at 8:42 P.M.; -Signed by ADON on 4/12/24 at 8:42 P.M.; -Received call from pharmacy stating that Physician A wanted to start the patient on IV Zosyn. Patient's chart stated that he/she had an allergy to penicillin and the pharmacist asked me to ask patient or family what the reaction was. Son stated that the reaction was that it caused blood clots. Pharmacist stated that Zosyn does not cause blood clots and that we were ok to hang the IV. Review of the resident's progress note, signed by the ADON on 4/12/24 at 8:42 P.M., provided by staff and received 9/12/24, showed a handwritten note, Nurse did talk to son, the source of history of antibiotic allergy which was cancelled in 2017 and son stated that the reason was that it caused blood clots. This information was reported to doctor and pharmacist and medication was cleared and approved for administration. Review of the progress notes, showed: -Service date/time: 3/25/24 at 11:43 P.M.; -Signed by Licensed Practical Nurse (LPN) B on 3/25/24 at 11:49 P.M.; -This nurse started patient on Zosyn IV as ordered. After 30 minutes of going back into the room to check on the patient, noticed that he/she was not him/herself. Patient stated that he/she did not feel good and he/she was yelling out, serum pressure oxygen (SPO2) was low, this writer applied oxygen at 4 liters (L) via nasal cannula, blood pressure was not reading. Physician A called left voicemail (LVM). Son called, made aware of resident's condition, and 911 called to have patient sent to hospital. Review of the progress notes, showed no documentation of the resident's behavior on 3/25/24, resident's signs and symptoms of allergy to penicillin, conversations between the resident's family and nursing staff, and conversations between nursing and pharmacy or physician. Review of the resident's hospital record, dated 3/25/24 at 11:35 P.M., showed: -Chief Complaint: Nurse hung antibiotic at rehab. Thirty minutes later, patient had respiratory rate and complaints of burning sensation. Patient is a Do Not Resituate (DNR, medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing or heart stops); -History of present illness: The onset was prior to arrival. He/She is an [AGE] year-old who is being treated at rehab facility for pneumonia. He/She was getting antibiotics and 30 minutes later when the staff went to check on, he/she was found less responsive and was having some difficulty breathing. Paramedics were called. Emergency Medical Service (EMS) report is not available. The prearrival report suggests that he/she was hypotensive (low blood pressure) and heart rate of 110. He/She was given two rounds of epinephrine intramuscularly (within or into a muscle). He/She was not noted to be wheezing. He/She was noted to be hypoxic (a condition that occurs when the body or part of the body does not receive enough oxygen at the tissue level). He/She was put on nonrebreather (a medical device that provides oxygen to patients in emergency situations) mask. Patient cannot provide any history. Further information as noted above in the triage; -EMS report: allergic reaction to intravenous line (IV) antibiotics, from rehab, 2 IM cpi given; -Vitals: 60/40 (low blood pressure is a reading lower than 90/60); -110 a-fib, unable to get O2 (oxygen); -Spoke with his/her son who is present at the bedside. Apparently visited him/her this afternoon and he/she was not feeling good at that time. He/She was not feeling well. He told the surgery place that he/she gets blood flow from penicillin. No other reaction was noted. DNR/DNI (Do Not Intubate) was confirmed with the son. During an interview on 9/11/24 at 12:18 P.M., the ADON said pharmacy called from the hospital. The resident had the allergies to penicillin and pharmacy asked if the resident would be able to tell them what happened. The resident could not. His/Her son was reached and the son said it almost killed him/her and gave (him/her) blood clots. They got an IV in him/her, and even pharmacy recommended running it slower, but the ADON could not confirm that for sure. They started that night, but he/she had a reaction and they sent him/her out 911. The ADON was not there at the time the resident was sent out. Physician A was contacted. The ADON looked for the note in the medical record. He/She said it happened a long time ago, but confirmed there was no other note on him/her and if there was no documentation, he/she did not want to say the physician was notified. The ADON already left when resident had a change in condition. LPN B hung the IV. LPN B was upset that the information was not conveyed to him/her regarding the reaction to penicillin. They stayed with the resident the first few minutes and for a regular antibiotic, they do checks for the first two hours. It's visually assessing the resident, eyes on the resident. The pharmacy said the allergy to penicillin was in there, but the severity was not documented, so that was why they wanted to contact someone in the family. The ADON did not remember if he/she took the order for the medication. The son said blood clots first, but pharmacy said it was not possible. The ADON went back to the son and said it was not on the list of reactions and not possible. The son said I am not medical, but the son said the blood clots. The ADON did not have almost killed him/her documented, but he/she realized he/she said it in the beginning of the interview. He/She did not want to say that for sure. The pharmacy called the facility. Someone else could have put the order in. The ADON checked the medial record and said the order was put in by Physician A, from what the ADON was able to see. The ADON was asked if he/she felt comfortable administering the Zosyn. The ADON said with the pharmacy saying it was ok, he/she felt comfortable administering medication. Anytime there is a new medication, they keep an eye on the resident whether it is a possible allergy or not. There is no protocol if there was uncertainty of symptoms or reaction to a medication. It should be the same situation with any antibiotic administered. They keep an eye on the resident. During an interview on 9/11/24 at 1:57 P.M., the Director of Pharmacy returned to the record in their system. The resident was allergic to penicillin, but no reaction was listed. They did put the order through. They talked to Physician A and he/she said the resident was resistant to all medications for a UTI, so the only option was Zosyn. The ADON talked to the son and the patient did not have an allergy to penicillin, just a history of blood clots. There is a letter from the daughter, who wrote in a letter that the patient was quite severely allergic to penicillin. The son talked to the ADON and the only reaction to penicillin was he/she had blood clots and that was why he/she was on Coumadin (anticoagulant medication that prevents and treats blood clots). The information blood clot reaction not from Zosyn did not come from pharmacy for the ADON to tell. The physician may have felt it was not a real allergy. The Director of Pharmacy was asked about a letter from the daughter he/she mentioned. He/She heard the daughter said the resident was allergic. The Director of Pharmacy just saw penicillin allergy in the chart, but no reaction was documented. There was no documentation of anaphylaxis in the medical record for what he/she could see. The allergy showed the reaction was blood clots. Pharmacy spoke to the physician and the physician was facilitating the order. There was no documentation of contact with nursing or with the ADON. If patient had a reaction of anaphylaxis, they would not have gone forward with that order. There was no documentation of severe anaphylaxis in the medical record. The resident was treated for anaphylaxis in the hospital and he/she had sepsis. The physician contacted the pharmacy to order it and the physician talked to the nurse. That was what they were told. Blood clots is what pharmacy was told the son said. It came from the ADON, but he/she but did not see it in the pharmacy records. He/She said it was what he/she was just told. During an interview on 9/11/24 at 2:48 P.M., the Administrator and Director of Nursing (DON) said they were here at the time the resident was admitted and were aware he/she went out to the hospital. The DON said he/she had allergies listed and the son talked to the nurse and they reported there was an allergy to it and the resident got blood clots. Blood clots was not an allergic reaction. The Administrator said Physician A was aware the son made a statement about penicillin causing blood clots. The information was from the nurse to the doctor. Physician A ordered the Zosyn because it was not a true side effect of penicillin and there was only a few antibiotics he/she could use. The son believed the resident was on blood thinner because of the allergy, but it was atrial fibrillation. The DON said when an order is entered, they have to click a button if physician is aware of the order, press if they want to continue to order or if the physician approved or not. The DON said she was here and the son did not say it could kill him/her. There was no other reaction other than blood clots. The DON was there when the IV or the peripheral was placed. The DON was not at the facility during the resident's change in condition. The son was hopeful and grateful because resident was combative and total care. The son did not want the resident to go out to the hospital. Allergies are located in the allergies tab in the medical record. The allergy to penicillin was documented, but no reaction was documented. Some residents cannot say what the reaction is, but they do inquire about allergies, even food allergies, before it is administered. The Administrator and DON only knew about contact with the son, no other family member called, sent a letter, or spoke to about allergies. The DON would have to look into the notes, but believed the nurse talked to the physician. She was certain nursing was in contact with pharmacy and the physician multiple times. It may not be documented, but the medication would not be sent over without the approvals. For antibiotics and any medication, there is an assessment, and nursing would take vitals. For antibiotics, it specifies the reason they are on it. Nursing was back in the room several times and at the half hour mark after administration. The resident had hypoxia and shortness of breath. They had been in there several times prior; they changed him/her because he/she was incontinent. The Administrator said she was sure the physician was on the phone with nursing. The order should not come over without physician approvals. If Physician A is not on the phone, he is electronically communicating with staff. The Administrator said they may not have policies requested by the surveyor for physician orders, IV medication administration, and change in condition. The DON said she will look for them. During an interview on 9/11/24 at 3:15 P.M., Physician A said he/she believed the pharmacy called to inform him/her the urine culture showed different bacteria. The cultures were looked at and Zosyn was recommended. Physician A wanted to review the record and call back. At 4:45 P.M., Physician A called back. The resident was confused and he/she had a UTI. He/She was on Macrobid. The pharmacy called and said it was MDRO and there was greater than 100,000 from the culture from March 14th, and was resistant other than Zosyn. He/She called the pharmacy to guide him/her. The other option that left was Zosyn. He/She went into sepsis due to UTI and was resistant to all medications. The only option left was Zosyn because he/she became septic. The order came from pharmacy. The information regarding allergies to blood clots was not clear on the penicillin allergy. Everything else was resistant in the urine culture. All 12 antibiotics were resistant to the bacteria. There was no discussion regarding resident being highly allergic or it could kill him/her. Anaphylaxis was not mentioned. The resident was also confused. It was one of the concerns. If the UTI was not treated, they have to consider hospital re-admission. They wanted to treat the UTI because it was sensitive. Physician A would not administer Zosyn if it was relayed the resident was highly allergic and it could kill him/her. Sometimes someone says they are allergic from 30 years ago. A lot of people say they are allergic and penicillin caused a rash. Labeling yourself allergic to penicillin, you are not able to take a lot of medications. If they stated blood clots, that is a mild allergy. It is unusual to have a blood clot allergy to penicillin. The resident was to treat the Citrobacter on March 14th. This is MDRO on the lab. Physician A asked pharmacy, and they said the only option was IV Zosyn. There was complete understanding he/she was on Macrobid and he/she was really confused. The fear was the resident not responding and he/she would go into sepsis. During an interview on 9/11/24 at 3:25 P.M., the resident's son said he did not remember the nurse's name he spoke to. He/She just stuck his/her head in the room. The phone was on his/her shoulder. He/She asked why did he/she have penicillin on the allergy list. He told him/her that it caused blood clots, he/she was highly allergic and that it could kill him/her. It had been on his/her list for 30 or 40 years. They updated it 2017 at the hospital. Apparently that was not listed on the reactions. The son left the facility at 6:30 P.M., they called him and and resident was sent to the emergency room at 11:00 P.M. The resident was gasping for air, they came in, and gave him/her a breathing treatment in the emergency room. They would not let the son in when he got there. There were two nurses and doctor in there. They said the resident was in critical condition. Penicillin allergy is on his/her list and they gave it to him/her anyway. They know they messed up and now he/she is on hospice and now his/her heart is damaged on one side. That was the indication he got from the doctor. It was a result of the Zosyn. The son said years ago, the resident had a blood clot and he/she was slumped over in the car. His/Her spouse thought he/she had the flu, so he/she gave the resident a penicillin capsule. He/She started having a reaction, so they drove to a car dealership, and they called EMS and took him/her to hospital. That was when they found out he/she was allergic to penicillin. That was 30 years ago. He/She had numerous venous thrombosis in the legs in his/her history. He/She had pin sized blood clots in the past. Anything with penicillin should be kept away from him/her. If there's bacteria, the physician has to be careful of what he/she prescribes. He/She is incapacitated now and is on hospice. The resident still had a UTI at the new facility and even at the hospital. At 3:43 P.M., the son called back and said someone from the hospital or the facility called him in the past and they said they did nothing wrong and he told the nurse it caused blood clots. The son confirmed in addition to blood clots, highly allergic and it could kill him/her were communicated to the nurse. During an interview on 9/11/24 at 4:00 P.M. the DON said the part of it could kill him/her meant the blood clots. The son was asked what the reaction would be, and he said it would cause blood clots. The resident was started on Eliquis (blood thinner) due to atrial fibrillation. He was asked if it was blood clots and he said I am not medical and that is the only reaction he knew he/she had. Once the resident was discharged from hospital, his/her son did not want him/her to come back. The day the resident received the Zosyn, it was an all day ordeal. He/She was demented and combative. The son thought sending him/her out would cause more confusion. The son told the resident, they have to stick you, they have an IV. They got the IV placed and re-visited back and forth with the pharmacy and doctor. It was never mentioned any amount of penicillin was lethal. The Administrator said the physician made the decision and there were limited antibiotics. There was no documentation of anaphylaxis and no shortness of breath. They did explore every opportunity of what happens with penicillin. The statement made tried to kill him/her that was when they were discharge planning at the hospital. They spoke to the physician who approved the medication. The son was aware and was okay with the medication. The physician was aware of the blood clots. Everything was a team effort. The son was aware Zosyn was administered, and convinced resident to take it. The DON was asked if the information was documented. The DON said all the documentation goes back to the order. There is a lot to do and select different options. She would have to check if there is documentation. If anything was refused, they would have documented it. They talked to the son and patient, and documented they inserted the IV and it is a task that pops up in the record. They document by exception. The Administrator said either pharmacy called the facility or they called pharmacy. Once the order goes to pharmacy, if they see an allergy, they will call. There is a safety there that would go through the pharmacist. She did not recall if the resident was administered other medications. The son was adamant about wanting the IV medications. She believed the son's take was he would convince him/her to take the IV and they could coordinate to give it when the son was here. The son thought it would be quicker and more effective. When the resident was admitted , he/she was already total care and the son was living in an imaginary world. The resident's insurance did not believe he/she was able to stay for rehab stay because he/she would not get better. He/She did not have the potential to improve from a rehab stay. His/Her condition was already poor so there was no other chance of improvement. During an interview on 9/11/24 at 4:39 P.M., the DON provided documentation from social service notes. The son did not mention it could kill him/her, but the social worker notes showed the son said the facility tried to kill resident. During an interview on 9/11/24 at 4:39 P.M., the ADON returned with the DON and Administrator. The ADON said he/she should have slowed down during the initial interview. If the son said it could kill him/her, it would have been in his/her note. The ADON said there was a lot of mentioning of it could kill him/her from the son, but it was after the resident received Zosyn. The Administrator said the they could have killed him/her part that was said by the son was not related to the blood clots. It was after what occurred when the penicillin was administered. The Administrator said they did not see it as a medication error. It was cleared by the pharmacist. They did not make a medication error. If the son said it almost killed him/her, they would have asked more questions. MO00240500

Based upon interview and record review, the facility failed to post a daily staffing report that indicated the total number of hours worked by nursing staff. This deficient practice has the potential to affect all 80 residents and visitors to the facility. This failure had the potential to inaccurately inform any resident or visitor to the facility of the available nursing staff caring for residents. Findings include: Review of the St. Luke's Surrey Place Staffing nurse staffing document, located on the receptionist counter of the facility, dated 07/31/24 indicated the facility's name, the resident census, the total number of licensed/unlicensed staff, and the shift the staff were working. However, the form did not indicate the total number of hours worked by the nurses and Certified Nurse Aides (CNAs) per shift/day. Review of St. Luke's Surrey Place Staffing nurse staffing documents dated 07/01/24 through 07/31/24 revealed the document did not indicate the total number of hours worked per nurses and CNAs during each shift. Interview on 08/01/24 at 9:35 AM the Director of Nursing (DON) stated she was unaware that the total number of hours worked by staff was needed on the form. The DON confirmed there was no policy on daily staff postings.

Based on observations, interviews, and record review, the facility failed to regularly offer/assist a resident with removal of facial hair to maintain good grooming and hygiene for 1 (Resident #100) of 2 sampled residents reviewed for activities of daily living. Findings included: A review of Resident #100's History and Physical Reports indicated the resident had diagnoses that included carpal tunnel syndrome (a condition that causes pain, tingling and numbness in the hand), spinal stenosis of the lumbar region (narrowing of the spinal canal, compressing the nerves traveling through the lower back), anxiety, and depression. A review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS indicated Resident #100 required limited assistance with personal hygiene. Review of a Care Plan, dated as initiated on 12/07/2022, revealed Resident #100 was care planned for activities of daily living (ADL) functional rehabilitation (rehab). The goal indicated the resident would function at an optimal level with ADLs. Interventions included providing assistance to support the resident's level of need. During an observation on 12/19/2022 at 2:53 PM, Resident #100 had long facial hair. The resident stated he/she required help with shaving, but that staff had not offered to assist. On 12/20/2022 at 2:40 PM, Resident #100 was observed sitting in a recliner in their room. The resident's facial hair remained long. During an interview at this time, Resident #100 stated no one had offered to shave them. The resident indicated they could not shave independently and last received a shave approximately three to four weeks ago when in the hospital. During an observation and interview on 12/21/2022 at 9:00 AM, Resident #100 was sitting in a wheelchair and had not been shaved. Resident #100 again verbalized the need to be shaved, the inability to shave independently, and lack of help from staff. In an interview on 12/21/2022 at 9:10 AM, Certified Nursing Assistant (CNA) #11 stated the CNAs were responsible for shaving the residents. CNA #11 observed Resident #100 and agreed the resident needed to be shaved. CNA #11 asked Resident #100 if the resident would like to be shaved and the resident responded yes. CNA #11 acknowledged she had not offered to shave the resident and could not provide any reason why she had not offered. During an interview on 12/21/2022 at 9:25 AM, the Director of Nursing (DON) stated residents should receive a shave every other day and as needed. Per the DON, it was the responsibility of the CNAs to shave residents. The DON observed Resident #100 and acknowledged the resident needed to be shaved. In an interview on 12/21/2022 at 11:10 AM, the DON and Administrator stated the facility did not have a policy or procedure for shaving a resident. The DON stated residents should be shaved as needed. In an interview on 12/21/2022 at 11:16 AM, the Administrator stated personal hygiene care should be offered and provided by the staff, if the resident was dependent on staff.

Based on observation, interview and record review, the facility failed to provide protective oversight for one resident (Resident #1) who had a change of condition and began to actively exit seek. The facility failed to ensure the resident was re-evaluated for an elopement risk, after multiple attempts to exit the facility and mistakenly thought he/she wore a wander guard device (a device use to prevent exiting from the building) attached to his/her person or wheelchair. The resident was observed via camera footage attempting to exit the facility in his/her wheelchair via the exit near the nurse's station on the Alpine hall, which is where the resident resided. The resident was later observed by a charge nurse attempting to exit the facility via his/her wheelchair via the front lobby. The resident was stopped by the charge nurse and taken back to his/her room. At approximately 2:30 A.M., the resident was observed via camera footage leaving his/her room via his/her wheelchair heading toward the front lobby and exiting the building to the parking lot. The resident sat in his/her wheelchair for approximately 12 to 14 minutes before he/she was found by a staff member who was returning to the building after being on his/her break. The sample was 3. The census was 65. Review of the facility's Elopement Policy, undated, showed: -Policy: It is the policy of the facility to provide a safe and secure environment for all residents. In the event of a resident elopement, it is the policy of the facility to implement its policies/procedures immediately to locate the resident in a timely manner; -Purpose: 1. To assure the safety and security of residents. 2. To establish policies and procedures in the event of a missing resident. 3. To train and maintain staff awareness of the importance of the resident safety and security; -Procedure: Staff noting the missing resident will immediately notify the charge nurse and the supervisor of the missing resident. -The charge nurse/supervisor will immediately inform the unit manger or Assistant Director of Nursing (ADON) who will notify the Director of Nursing (DON) and Executive Director; -A missing resident elopement search team will include the following: -Off hours: All available personnel (with the exception of staying for resident care as determined by the supervisor), are to report to the neighborhood with the missing resident; -The charge nurse/supervisor will direct staff to begin search immediately and will overhead page from the telephone: Mr./Mrs. Green Jeans and the neighborhood and repeat three times; -Organize and institute a thorough search of the facility and surrounding grounds. During non business hours the charge nurse/supervisor will direct assignments; -When the resident is located, notify all of the departments who were alerted when the resident was determined missing. Make an overhead announcement of all clear.; -Supervisor will notify the physician, family, power of attorney, administrator and DON; -The charge nurse will complete a full head to toe assessment with vital signs and document in resident record; -An order for a wander guard will be obtained, resident photo will be obtained and the supervisor will update the elopement risk binder on each division and at the front desk; -Supervisor will record serial number and location of wander guard bracelet on the log; -Supervisor will ensure the resident's care plan is updated with new interventions. Review of the facility's Change in Resident Condition Policy, dated 1/2021, showed: -Purpose: To ensure that changes in resident condition are communicated to the appropriate individuals; -Procedure: When nursing staff becomes aware of a resident change in condition, they will inform the following: 1. Attending Physicians 2. Resident Family and Power of Attorney (POA) if appropriate; -Charting and documentation of changes in patient condition will be documented in the resident's medical record. This will include date and time of the condition change notification of physician date and time, notification of family and POA date and time. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/19/21, showed: -No cognitive impairment; -No moods or behaviors; -Limited assistance with locomotion on and off the unit; -Extensive assistance with transfer to wheelchair; -Diagnoses of cancer, medically complex conditions, [CONDITION(S)], high blood pressure, urinary tract infection, anxiety disorder and asthma; -No wandering or elopement alarm. Review of the resident's medical record of assessments and treatments, dated 5/12/21, showed: -Elopement attempts, Elopement Risk Score: No history; -Wandering Elopement, Elopement Risk Score: No; -Dementia Diagnosis, Elopement Risk Score: No; -Psychotic Behavior, Elopement Risk Score: No. Review of the resident's medical record, showed no documentation of an order for a wander guard device. Review of the facility's camera footage with the Maintenance Director at 8:00 A.M. on 6/4/21, showed: On 5/27/21: -At approximately 10:49 P.M., the resident was on the Alpine hall in his/her wheelchair going down the hall toward the nurse's station. The resident attempted to open the door near the nurse's station without success. The resident was redirected by staff; -At approximately 10:59 P.M., the resident attempted to open the door near the nurse's station without success. The resident was redirected; -At approximately 11:46 P.M., the resident attempted to open the door near the nurse's station without success. There was no one at the nurse's station at that time; On 5/28/21: -At approximately 12:33 A.M., the resident wheeled himself/herself toward the from lobby and attempted to exit the building. The resident was stopped by a staff member and brought back inside. During an interview, the Maintenance Director said there was a wander guard system on the front door. Review of the resident's medical record, showed no documentation of the resident's change of condition or of this attempt to elope from the building and no documentation of any interventions put into place. Further review of the facility's camera footage with the Maintenance Director, dated 5/28/21, showed: -At approximately 1:24 A.M., the resident came out of his/her room in his/her wheelchair, went toward the nurse's station and attempted to go out the door near the nurse's station without success; -At approximately 2:31 A.M., the resident came out of his/her room in his/her wheelchair on the Alpine hall and went through the double doors toward the dining/front lobby. At that time, there were two staff members seen at the Alpine nurse's station; -At approximately 2:37 A.M., the resident went out the front lobby door in his/her wheelchair. At that time, there were two staff members seen at the Alpine nurse's; -At approximately 2:47 A.M., a staff member got up from the Alpine nurse's station and went to the resident's room. The staff member came out of the resident's room and went toward the front lobby, but did not go out the front door; -At approximately 2:52 A.M., a staff member got out of his/her car on the parking lot, passed the resident and entered the facility; -At approximately 2:53 A.M., a staff member goes through the lobby, to the outside, followed by three other staff members to get the resident and bring him/her back into the facility. Review of the resident's nurse's note, dated 5/28/21 at 3:03 A.M., showed the resident was very confused and had been attempting to elope multiple times throughout the night, despite redirection. At around 2:30 A.M., a certified nurse aide (CNA) notified this nurse that a resident went through the closed double door. By the time this nurse went to get the resident, he/she was no where to be found and notified the night supervisor. The resident was later found in the parking lot. A wander guard was placed on the resident and he/she was again taken to his/her room. The resident is laying in bed at this time. The resident to be closely monitored. Review of the resident's medical record, showed no documentation of a reassessment for elopement risk. During an interview on 6/7/21 at 7:07 A.M., CNA A said the resident had been restless the entire night. This was not normal for the resident. The resident was trying to go out the door near the nurse's station on the Alpine hall. The resident was saying his/her spouse was outside. Later in the evening, the resident attempted to go outside and the charge nurse stopped the resident because the wander guard alarm went off. Later in the night, a new CNA came in the facility to tell the supervisor a resident was outside. CNA A said he/she did not know the resident had gotten outside. This would be considered an elopement. During an interview on 6/7/21 at 8:49 A.M., CNA B said he/she was outside in his/her car on a break. He/she did not notice the resident until he/she was getting out of his/her car and about to go into the facility. The resident was sitting outside in his/her wheelchair in a gown. CNA B tried to talk to the resident but the resident would not respond. CNA B said he/she was new to the facility and did not know the resident, so he/she went inside to get some assistance. During an interview on 6/7/21 at 10:20 A.M., Nurse C said she had been told in report the resident had been acting confused. The resident had been trying to elope through the doors near the nurse's station on Alpine hall. Later in the evening, the resident went through the double doors which lead to the front lobby. He/she followed the resident to see how far he/she would go. Nurse C assumed the resident had on a wander guard, but did not check to see if the resident had a wander guard attached. When the resident tried to exit the front lobby door, he/she stopped the resident and the wander guard system sounded. Nurse C said later he/she found out the wander guard sounded only because of the keys to the medication cart had a wander guard bracelet on it. Nurse C said around 2:30 A.M., he/she was sitting at the nurse's station charting. CNA A said the resident was going through the double doors. Nurse C assumed the resident had a wander guard, and so he/she could not get out of the building. Nurse C said about 10 minutes later, he/she got up to go look for the resident. He/she checked all of the halls, asking staff if they had seen the resident. No one had seen the resident. Nurse C said he/she got the supervisor and they both continued to look for the resident. A CNA came in from outside and said a resident was outside by the cars. They went to get the resident and Nurse C realized then, that he/she had a wander guard bracelet on the keys, in his/her pocket. During an interview on 6/7/21 at 10: 39 A.M., Nurse D said at approximately 2:30 A.M., Nurse C came down the hall looking for the resident. Nurse D said no one had seen the resident. Nurse D said he/she got up and started looking for the resident. Since it was the night shift, a code was not called. A CNA came in from break, saying a resident was outside. This was a new CNA. Nurse D said he/she went to get the resident and brought him/her back in the facility. The resident was assessed and a wander guard was placed on the resident at that time. Nurse D said he/she had assumed the resident had a wander guard because the system sounded. He/she then realized it was Nurse C, with the wander guard bracelet on the keys, that activated the system. Nurse D said he/she should not have assumed the resident had on a wander guard. When Nurse C came and got him/her, he/she did not know the resident was outside. During an interview on 6/9/21 at 11:30 A.M., the ADON and the administrator said the resident has metastasizing brain cancer which may have caused her condition change. The wander guard that triggered the front door was on the medication cart key ring. The wander guard was placed on the key ring to prevent staff from taking the keys home. The ADON said Nurse C assumed the resident had on a wander guard but did not check to see if the resident had a wander guard attached. Nurse D should have check to see if the resident had a wander guard attached. The administrator said the staff did look for the resident in a timely manner. The facility has a assessment process for elopement which will determine if a wander guard is needed. The administrator said in hindsight, if the charge nurse would have checked for a wander guard attached to the resident, the resident might have not gotten out. During an interview on 6/9/21 at 1:28 P.M., Physician E said the facility did make him/her aware the resident eloped from the building, but he/she did not realize the resident eloped at 2:30 A.M. He/she thought it was in the afternoon. Physician E said considering the resident wheels himself/herself around, the resident should be monitored closely. During an interview on 6/10/21 at 11:45 A.M., the DON and the administrator said an elopement assessment is completed at the time of admission. If a resident starts to show exit seeking behavior, a reassessment should be completed. The charge nurse, clinical supervisor or DON can get an order for a wander guard and place it on the resident or their assisted mobile device. MO 145

Based on interview and record review, the facility failed to failed to obtain consistent, accurate weights, necessary for assessing residents' nutritional status for four of 11 residents reviewed for nutritional needs (Residents #11, 16, 19 and 22). The facility failed to maintain scales, record weights accurately or reweigh residents who had a large weight gain or weight loss, which prevented an accurate assessment of nutritional status. This had the potential to affect all residents who might experience a weight loss or gain outside the normal parameters. The census was 62 with 44 residents in certified beds. 1. Review of Resident #11's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/20, showed the following: -admitted on [DATE]; -Adequate hearing; -Impaired vision; -Clear speech; -Ability to express ideas and wants: Usually understood; -Ability to understand others: Usually understood; -No behavioral symptoms; -Transfer: Extensive assistance, two or more person assistance required; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -No signs of a swallowing disorder. No weight loss of 5% or more in the last month or 10% or more in the last six months; -Care area assessment: Care areas triggered in nutritional status and dehydration should be addressed in the care plan. Review of the resident's weights detail report, showed the following: -On 11/19/20, the resident weighed 190 pounds (lbs); -On 12/18/20, the resident weighed 148.8 lbs. 2. Review of Resident #16's quarterly MDS, dated [DATE], showed the following: -admitted on [DATE]; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -Brief Interview for Mental Status score of 15 out of a possible 15 (a score of 13-15 indicates cognitively intact); -No behavioral symptoms; -Transfer: Extensive assistance, two or more person assistance required; -Walk in room: Activity did not occur; -Functional limitation in range of motion: Impairment on both sides of upper extremities; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -No signs of a swallowing disorder. No weight loss of 5% or more in the last month or 10% or more in the last six months; -Care area assessment: Care areas triggered in nutritional status and dehydration should be addressed in the care plan. Review of the resident's weights detail report, showed the following: -On 9/21/20, the resident weighed 176.6 lbs; -On 10/7/20 at 9:21 P.M., the resident weighed 246 lbs. At 9:29 P.M., the resident was re-weighed at 191 lbs. 3. Review of Resident #19's quarterly MDS, dated [DATE], showed the following: -admitted on [DATE]; -Weighed 185 lbs at admission; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -Brief Interview for Mental Status score of 15; -No behavioral symptoms; -Transfer: Extensive assistance, two or more person assistance required; -Walk in room: Activity did not occur; -Functional limitation in range of motion: Impairment on both sides of lower and upper extremities; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -No signs of a swallowing disorder. No weight loss of 5% or more in the last month or 10% or more in the last six months; -Care area assessment: Care areas triggered in nutritional status and dehydration should be addressed in the care plan. Review of the resident's weights detail report, showed the following: -On 11/8/20, the resident weighed 170.8 lbs; -On 12/11/20, the resident weighed 184.8 lbs; -On 1/10/21, the resident weighed 153 lbs. 4. Review of Resident #22's MDS, dated [DATE], showed the following: -admitted on [DATE]; -Weighed 222 lbs at admission; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -Brief Interview for Mental Status score of 14; -No behavioral symptoms; -Transfer: Extensive assistance, two or more person assistance required; -Functional limitation in range of motion: Impairment on one side of lower extremities; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -No signs of a swallowing disorder. No weight loss of 5% or more in the last month or 10% or more in the last six months; -Care area assessment: Care areas triggered in nutritional status and dehydration should be addressed in the care plan. Review of the resident's weights detail report, showed the following: -On 12/4/20, the resident weighed 202.2 lbs; -On 12/12/20, the resident weighed 194.6 lbs; -On 12/14/20, the resident weighed 136.6 lbs. 5. During an interview on 1/20/21 at 11:45 A.M., Certified Nurses Aide (CNA) P said the nurse gave the CNAs a list of people they were supposed to weigh when they got there in the morning. The sheets would tell the staff which scale to use; the wheelchair scale or the Hoyer lift scale. They were supposed to record the weights on the list and give it to the nurse when they were done. Sometimes it was confusing because the scale would weigh people in kilograms (kg). He/she just recorded what the scale said and gave it to the nurse to change to lbs. He/she did not make the calculations for wheelchairs or Hoyer lifts. 6. Review of the registered dietician's (RD) weight record notes, dated 9/24/20, showed the following: -Too many discrepancies in weights; need consistent methods of measurements; -Weights taken down on paper needed dates, otherwise were useless to RD; -Staff needed to increase attention to correct patient names when documenting; -Goals included eliminating mathematical/conversion errors to increase consistency. During an interview on 1/20/21 at 3:50 P.M., the RD said she was frustrated with the scales and weights. She told the supervisors about the inconsistencies with the weights and recommended training in taking weights because some staff were weighing residents in kgs and some were using lbs. There was some confusion when the weights were transferred from kgs to lbs, and the staff needed to be more consistent. She told the maintenance director the Dakota Hall scales were not weighing right. The scales could be off 30-40 lbs sometimes. The Hoyer scales measured weights in kgs and the numbers would be off by a six pound average when converted to lbs. She was very frustrated with the fluctuations. It was hard to assess a resident for nutritional needs or develop interventions when there was inconsistent weights. 7. Record review of the facility's scale calibration documentation, dated 1/20/21, showed the following: -The Canyon Creek Hall Befour wheelchair scale calibrated on 7/2/19 and on 11/27/20; -The Canyon Creek Drive Hall Hoyer lift scale calibrated on 10/31/19 and on 12/30/20; -The Dakota Bluffs Hall Liko Hoyer lift scale calibrated on 10/31/19 and on 12/30/19; -The Dakota Bluffs Hall Detecto wheelchair scale calibrated on 9/9/19 and on 12/8/20. Review of the Detecto manufacturer's recommendation provided by the facility on 1/27/21 showed the following: -Please be advised that Cardinal/Detecto Scale manufacturing company only makes the following statement as a recommendation, as individual state requirements may be different based on use and application; -For all clinical model scales, we recommend a minimum six month calibration cycle. During an interview on 1/20/21 at 3:00 P.M. and 1/21/21 at 1:30 P.M., the maintenance director said the Detecto scales had a manufacturer's recommendation to be calibrated every six months. He could not find the manufacturers' information on the other scales but thought they should be calibrated annually. Their clinical engineering department calibrated the scales, as he was not qualified to do this. The facility did not have a regular schedule for calibrating the scales. The clinical engineering department would recalibrate anytime they were called out to do a repair on the scales. 8. Review of the facility's undated weight management process, showed the following: -Objective: Promotes the appropriate monitoring of weight to improve resident outcomes and reduce unintended weight loss; -Process for post acute patients: *Patients will be weighed on admission and then weekly for the remainder of their stay. The physician, case management or the registered dietician may order a different frequency for the better management of the patient; *The Certified Nurse Aides will obtain the weight as assigned, use the same scale every time, and then document the weight in care tracker; *The nursing supervisor will be responsible for ensuring that weights are completed, documented and accurate. If there is a discrepancy of five percent or more weight change, the nursing supervisor or registered dietician will request a reweigh of that particular patient/resident; -Process for long term care residents: *Residents will be weighed on admission and then weekly for four weeks; *After the first four weeks, the resident will be weighed monthly. The physician, case management or the registered dietician may order a different frequency for the better management of the patient; *The Certified Nurse Aides will obtain the weight as assigned, use the same scale every time, and then document the weight in care tracker; *The nursing supervisor will be responsible for ensuring that weights are completed, documented and accurate. If there is a discrepancy of five percent or more weight change, the nursing supervisor or registered dietician will request a reweigh of that particular patient/resident. 9. During an interview on 1/20/21 at 9:15 A.M., the Director of Nursing (DON) said residents in rehab were weighed weekly and the residents in long term care are weighed weekly for a month and then monthly unless the physician or RD decides differently. The documentation of weights showed an inconsistency in the amount of weight being lost or gained. It could be confusing because some of the scales measured weights in kgs. She was not sure if the problem was with the scales or the staff taking the weights. The director of maintenance was responsible for calibrating the scales as needed. They followed the manufacturers' guidelines in determining when the scales should be calibrated. CNAs usually took the residents' weights on their shower day. The nursing supervisors would make a list of residents who needed to be weighed, which scale they would be weighed on and the staff responsible for getting their weights for that day. The CNAs would record the weights on paper and then give it to the nurse who would record it in the electronic care tracker. It could be hard to assess a resident's nutritional status if weights were not correct. 10. During an interview on 1/27/21 at 12:30 P.M., the administrator said all residents on a specific hall would use the scales designated for that hall unless there was a reason to weigh them on another hall. The scales should be calibrated according to the manufacturers recommendations. They did not have a policy or procedure for regular calibrations. The weights being recorded were sometimes inconsistent, but she did not know if it was a problem with the scales or with staff and the documentation. MO 653

Based on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation system in proper working condition when all residents' bathrooms on the C hallway did not have functioning exhaust vents. This affected all residents on the C hallway. The facility had a capacity of 80 residents with a census of 67. 1. Observation on 8/21/19 beginning at 9:00 [NAME]M., showed the exhaust ventilation system, in all residents' bathrooms of the C hallway, did not work when tested . During an interview on 8/21/19, at approximately 3:15 P.M., the maintenance supervisor said he did not know the residents' bathroom exhaust system did not work. He said the facility had recently had some work done and the ventilation was worked on at that time.

Based on interview and record review, the facility failed to complete the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, Form CMS- ) for one sampled resident (Resident #5) out of three sampled residents. The facility census was 67. Record review of Resident #5's SNF Beneficiary Protection Notification Review showed the following: - The resident's Medicare Part A skilled services episode had a start date of 3/16/19; - The resident's last covered day of Part A service was 3/28/19; - A SNF ABN, Form CMS- was not provided to the resident because the resident was discharged from the facility and did not receive non-covered services. Spoke with POA (Power of Attorney) who was not concerned about charges but wanted to ensure patient was able to be in Medicaid bed and bill Medicaid for coverage. Record review showed the resident did not discharge from the facility after Medicare Part A services ended, but continued to reside in the facility. Record review showed there was not a SNF ABN, CMS- form completed for the resident's Medicare Part A Stay. During an interview on 8/22/19 at 9:00 [NAME]M., the Social Services Director said the following: - The resident's payer source changed to Medicaid after the resident ended Medicare Part A services and the resident continued to live in the facility; - He did not think the facility had to provide a SNF ABN to the resident or resident representative when the payer source changed from Medicare Part A to Medicaid; - He only has the resident or resident representative sign the SNF ABN when the resident's payer source changes from Medicare Part A to private pay. During an interview on 8/22/19 at 7:30 P.M., the Administrator said they did not issue a SNF ABN to the resident or resident representative because the payer source went from Medicare Part A to Medicaid.

Based on interview and record review, the facility staff failed to provide written notification of transfer to the resident or the resident's representative for four residents (Residents #7, #20, #34, and #66) who transferred to the hospital. The facility census was 67. 1. Review of Resident #7's medical records, showed staff documented the resident was admitted to the facility on [DATE]. Review of the resident's transfer form, dated 7/27/2019, showed staff documented there was a medical reason for transfer because the resident fell a day ago and now showed symptoms of pain and swelling in his/her left hip. Review of the resident's nurses notes, dated 7/27/2019, showed the resident complained of pain in the left upper leg. When turning the resident to change his/her brief and when the resident stood for the transfer his/her pain level became intolerable. The resident had a hard swollen area to the left hip and the physician was notified and gave orders to send the resident to the hospital. Review of the resident's transfer form, dated 8/4/19, showed the the resident had an injury from a fall with discomfort to the right hip and the reason for the transfer was medically indicated to acute hospital. Review of the resident's nurses note, dated 8/4/19, showed staff documented the resident was found on the floor in the middle of his/her room on his/her back and said he/she fell . The resident complained of pain in his/her right hip and leg was lifted up slightly. The physician was notified of the fall and gave an order for [REDACTED]. Review of the resident's record showed staff did not provide written notification to the resident or resident's representative upon the resident's transfers to the hospital with the required information of the reason for transfer, effective date of transfer, location to which the resident was transferred, a statement of the resident's appeal rights, the name address and telephone number of the State Long-Term Care Ombudsman, for nursing facility residents with intellectual and developmental disabilities or related disabilities the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities, for nursing facility residents with mental disorders or related disabilities the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. 2. Review of Resident #20's medical record showed the resident was admitted on [DATE]. Review of the resident's facility transfer sheet, dated 7/17/2019, showed staff documented the resident was transferred to the Emergency Department by ambulance. The resident was transferred for a medical reason of mental status change and increased confusion throughout the day. Review of the resident's nurses notes, dated 7/17/2019, showed staff documented the resident was very confused. The resident had three plus [MEDICAL CONDITION] (swelling that when pressure is applied, leaves an indentation of five to six millimeters that takes up to thirty seconds to rebound) in both left extremities. The resident became increasingly confused and disrobing in his/her room. The physician was notified and ordered the resident to go to the emergency room for evaluation. The resident left the facility at 10:15 P.M. by ambulance to the emergency room . Review of the resident's record showed staff did not provide written notification to the resident or resident's representative upon the resident's transfer to the hospital with the required information of the reason for transfer, effective date of transfer, location to which the resident was transferred, a statement of the resident's appeal rights, the name address and telephone number of the State Long-Term Care Ombudsman, for nursing facility residents with intellectual and developmental disabilities or related disabilities the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities, for nursing facility residents with mental disorders or related disabilities the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. During an interview on 8/22/2019 at 9:55 [NAME]M., the Administrator said he/she did not give the resident a written transfer notice because the resident was going to the hospital and was supposed to come back. 3. Review of Resident #66's medical record showed the resident was admitted on [DATE]. Review of the resident's nurses notes dated, 6/10/2019, showed staff documented the resident was complaining of shortness of breath and had difficulty breathing; the resident's oxygen saturation was found to be 84 percent (%) on two liters of oxygen. The resident was encouraged to cough and produced thick yellow brown sputum (mixture of saliva and mucus). The physician was notified and the resident was sent to the emergency room . Review of the resident's record showed staff did not provide written notification to the resident or resident's representative upon the resident's transfers to the hospital with the required information of the reason for transfer, effective date of transfer, location to which the resident was transferred, a statement of the resident's appeal rights, the name address and telephone number of the State Long-Term Care Ombudsman, for nursing facility residents with intellectual and developmental disabilities or related disabilities the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities, for nursing facility residents with mental disorders or related disabilities the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. During an interview on 8/22/2019 at 9:55 [NAME]M., the Administrator said he/she did not give the resident a written transfer notice because the resident was going to the hospital and was supposed to come back. 4. Review of Resident #34's medical record showed the resident was admitted to the facility on [DATE]. Review of the resident's transfer form, dated 6/26/19, showed staff documented the medical reason for transfer to the hospital to be gastrointestinal. Staff also noted an unstageable pressure ulcer on the sacral area. Review of the resident's nurses notes, dated 6/26/19, showed staff documented they reported critical laboratory results to the resident's physician. Staff also noted receipt of a physician's orders [REDACTED]. Further review of the resident's nurses notes showed on 6/27/19, staff documented the resident was admitted to the hospital. Review of the resident's record showed staff did not provide written notification to the resident or the resident's representative upon the resident's transfer to the hospital with the required information of the reason for transfer, effective date of transfer, location to which the resident was transferred, a statement of the residents appeal rights, the name address and telephone number of the State Long-Term Care Ombudsman, for nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities, and for nursing facility residents with mental disorders or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. 5. During an interview on 8/22/2019 at 7:30 P.M., the Administrator said facility staff did not complete written transfer notices for residents who went to the hospital, because they did not know they were supposed to do them when residents went to the hospital.

Based on interview and record review, the facility failed to ensure that 10 out of 33 residents (Residents #10, #15, #7, #4, #8, #9, #11, #12, #13 and #14) on one of the units received their medications and/or treatments as ordered. The census was 90. 1. Review of Resident #10's face sheet, showed the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-Sepsis (a potentially life-threatening condition caused by the body's response to an infection) with bacteremia (the presence of bacteria in the blood); -status [REDACTED]. Review of the facility's wound tracking report, showed the resident was admitted with: -Unstageable pressure sore (known but not stageable due to coverage of wound bed by slough (mass of dead tissue separated from surrounding living tissue) and/or eschar (dead tissue)) to his/her right knee; -Stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister) to his/her left knee; -Unstageable pressure sore to his/her left elbow; -Unstageable pressure sore to his/her right elbow; -Deep tissue injury pressure sore to his/her sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis); -Unstageable pressure sore to his/her right chest. Review of the resident's physician order [REDACTED]. -[MEDICATION NAME] topical (Santyl, a sterile enzymatic [MEDICATION NAME] ointment), apply 2 millimeter (mm) thick to the wound bed (approximately the thickness of a nickel) then apply non-stick [MEDICATION NAME] (dressing) and kerlix (gauze wrap) and tape daily at 9:00 [NAME]M.; -[MEDICATION NAME]-[MEDICATION NAME] B topical ([MEDICATION NAME], a double antibiotic ointment), apply ointment topically to all wounds daily at 9:00 [NAME]M.; -Humalog (rapid-acting insulin), administer per sliding scale as follows based on blood sugar level (accuchecks) with meals at 8:00 [NAME]M., 12:00 P.M. and 5:00 P.M.: -131-180, give 2 units; -181-240, give 4 units; -241-300, give 6 units; -301-350, give 8 units; -352-400, give 10 units; -If over 400, obtain a stat (immediately) lab glucose and call the physician with the results. Review of the resident's Medication Administration Record [REDACTED] -Topical creams not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED].M.; -Humalog sliding scale not administered at 12:00 P.M.; -The documented reason for not administering the insulin: Not done due to 12:00 P.M. blood sugar was not obtained due to one nurse and one CMT. 2. Review of Resident #15's face sheet, showed the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's wound tracking report, showed the resident was admitted with a left heel diabetic ulcer and a left great toe diabetic ulcer. Review of the resident's POS, dated 12/2018, showed: -[MEDICATION NAME] (treats high blood pressure) 5 milligrams (mg) by mouth (PO) two times daily at 9:00 [NAME]M. and 5:00 P.M.; -Aspirin 81 mg PO daily at 9:00 [NAME]M.; -Carvedilol (treats high blood pressure and heart failure) 25 mg PO two times daily at 9:00 [NAME]M. and 5:00 P.M.; -[MEDICATION NAME] (topical antiseptic) 0.12% oral liquid swish and spit 15 milliliters (ml) two times daily at 9:00 [NAME]M. and 5:00 P.M.; -Vitamin D3 (supplement) 1000 units PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (treats high blood pressure) 0.1 mg two tablets (0.2 mg) PO two times daily at 9:00 [NAME]M. and 5:00 P.M.; -[MEDICATION NAME] topical apply 2 mm thick to the left heel wound bed daily at 9:00 [NAME]M.; -[MEDICATION NAME] (treats occasional constipation) 100 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (antifungal) 1% topical cream to affected areas two times daily at 9:00 [NAME]M. and 5:00 P.M.; -[MEDICATION NAME] (treats ulcers of the stomach and intestines and to prevent intestinal ulcers) 20 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (for nasal congestion) 100 micrograms (mcg) two sprays in each nostril daily at 9:00 [NAME]M.; -Folic acid (treats [MEDICAL CONDITION]) 0.4 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] ([MEDICATION NAME] binder) 800 mg PO three times daily with meals at 8:00 [NAME]M., 12:00 P.M. and 4:30 P.M.; -[MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME] (antimicrobial) ointment to left heel daily at 9:00 [NAME]M. Review of the resident's MAR for 12/31/18, showed: -10 out of 10 ordered PO medications not administered at 9:00 [NAME]M. -The documented reason for not administering the medications: [REDACTED] -Nasal spray not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] -Topical creams not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] 3. Review of Resident #7's face sheet, showed the resident admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's POS, dated 12/2018, showed: -[MEDICATION NAME] 1% (steroid) topical cream, apply to reddened areas on face two times daily at 9:00 [NAME]M. and 5:00 P.M.; -[MEDICATION NAME] 2% (antifungal) topical cream, mix with [MEDICATION NAME] 1% topical cream and apply to reddened areas on face two times daily at 9:00 [NAME]M. and 5:00 P.M. Review of the resident's MAR for 12/31/18, showed: -Topical creams not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] Review of the resident's POS, dated 1/2019, showed: -Calcium-vitamin D (supplement) 500 mg-200 units by mouth (PO) three times daily with meals at 9:00 [NAME]M., 2:00 P.M. and 5:00 P.M.; -Carvedilol 6.25 mg PO every 12 hours at 9:00 [NAME]M. and 9:00 P.M.; -Vitamin D3 800 units PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (blood thinner) 75 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (for high blood pressure) 180 mg/24 hour extended release capsule PO daily at 9:00 [NAME]M.; -Dorzolamide-[MEDICATION NAME] (for [MEDICAL CONDITION]) 2.23%-0.68% ophthalmic solution, administer one drop in the left eye two times daily at 9:00 [NAME]M. and 5:00 P.M.; -[MEDICATION NAME] (diuretic) 40 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] 1% topical cream, apply to reddened areas on face two times daily at 9:00 [NAME]M. and 5:00 P.M.; -[MEDICATION NAME] 2% topical cream, mix with [MEDICATION NAME] 1% topical cream and apply to reddened areas on face two times daily at 9:00 [NAME]M. and 5:00 P.M.; -Memantine (for dementia) 5 mg PO two times daily at 9:00 [NAME]M. and 5:00 P.M.; -Polyethylene [MEDICATION NAME] (stool softener) 3350 dissolve one packet in 8 ounces of liquid PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (for depression) 75 mg PO daily at 9:00 [NAME]M. Review of the resident's MAR for 1/6/19, showed: -9 out of 9 ordered PO medications not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] -Eye drop not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] -2 out of 2 ordered topical creams not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED].M. 4. Review of Resident #4's face sheet, showed the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's POS, dated 1/2019 showed: -Aspirin 81 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (vitamin B12) 1000 mcg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] 40 mg PO every other day at 9:00 [NAME]M.; -[MEDICATION NAME] 20 mg PO two times daily at 9:00 [NAME]M. and 5:00 P.M.; -[MEDICATION NAME] (anticonvulsant) 100 mg PO three times daily at 9:00 [NAME]M., 5:00 P.M. and 9:00 P.M.; -[MEDICATION NAME]-senna (stool softener) PO two times daily at 9:00 [NAME]M. and 9:00 P.M. Review of the resident's MAR for 1/6/19, showed: -6 out of 6 ordered PO medications not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED]. 5. Review of Resident #8's face sheet, showed the resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's POS, dated 1/2019, showed: -[MEDICATION NAME] (Uric acid reducer) 300 mg PO daily at 9:00 [NAME]M.; -Atorvastatin (cholesterol medication) 40 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (vitamin D3) 2,000 units PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] sulfate 325 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] 60 mg PO two times daily at 9:00 [NAME]M. and 5:00 P.M.; -Magnesium oxide (mineral supplement) 400 mg PO daily with breakfast at 8:00 [NAME]M.; -[MEDICATION NAME] (high blood pressure medication) 50 mg PO two times daily; check blood pressure and pulse. Hold and call physician for systolic blood pressure below 90 or pulse below 50; -Potassium chloride (mineral supplement) 20 milliequivalents (mEq) PO two times daily with meals at 8:00 [NAME]M. and 5:00 P.M. Review of the resident's MAR for 1/6/19, showed: -8 out of 8 ordered PO medications not administered at 8:00 [NAME]M. and at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED]. 6. Review of Resident #9's face sheet, showed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's POS, dated 1/2019, showed: -[MEDICATION NAME] ophthalmic solution (artificial tears) instill one drop in both eyes two times daily at 1:00 P.M. and 5:00 P.M. Review of the resident's MAR for 1/6/19, showed: -Eye drop not administered at 1:00 P.M.; -The documented reason for not administering the medication: Not done due to one nurse and one CMT until 4:00 P.M. 7. Review of Resident #11's face sheet, showed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's POS, dated 1/2019, showed: -Aspirin 81 mg PO daily at 9:00 [NAME]M.; -Calcium [MEDICATION NAME] 500 mg PO two times daily at 9:00 [NAME]M. and 5:00 P.M.; -Vitamin D3 1000 units PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] sulfate 325 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (treats allergies [REDACTED].M.; -[MEDICATION NAME] 25 mg PO two times daily at 9:00 [NAME]M. and 5:00 P.M.; -[MEDICATION NAME] (treats low blood pressure) 5 mg PO two times daily at 9:00 [NAME]M. and 5:00 P.M.; -Multivitamin PO daily at 9:00 [NAME]M.; -Ensure (supplement) compact 118 ml PO three times daily after meals at 9:00 [NAME]M., 1:30 P.M. and 5:30 P.M.; -Refresh (lubricating eye drops) 0.5% one drop in both eyes every four hours at 9:00 [NAME]M., 1:30 P.M. and 5:30 P.M. Review of the resident's MAR for 1/6/19, showed: -8 out of 8 ordered PO medications not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] -Eye drop not administered at 9:00 [NAME]M.; -The documented reason for not administering the medication: Not done due to not appropriate at this time; -Supplement not administered at 9:00 [NAME]M.; -The documented reason for not administering the medication: Not done due to not appropriate at this time. 8. Review of Resident #12's face sheet, showed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's POS, dated 1/2019, showed: -Aspirin 81 mg PO daily at 9:00 [NAME]M.; -Donepezil (Alzheimer's medication) 10 mg PO daily at 9:00 [NAME]M.; -Ezetimibe (cholesterol medication) 10 mg PO daily at 9:00 [NAME]M.; -Ketotifen ophthalmic (for itchy eyes) one drop in both eyes two times daily at 9:00 [NAME]M. and 5:00 P.M.; -Levetiracetam (anticonvulsant) 1500 mg PO two times daily at 9:00 [NAME]M. and 5:00 P.M.; -Losartan (treats high blood pressure) 100 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (treats overactive [MEDICAL CONDITION]) 5 g PO every other day at 9:00 [NAME]M.; -[MEDICATION NAME] 50 mg PO two times daily at 9:00 [NAME]M. and 5:00 P.M. Review of the resident's MAR for 1/6/19, showed: -7 out of 7 ordered PO medications not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] -Eye drop not administered at 9:00 [NAME]M.; -The documented reason for not administering the medication: Not done due to not appropriate at this time. 9. Review of Resident #13's face sheet, showed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's POS, dated 1/2019, showed: -[MEDICATION NAME] (antianxiety) 0.125 mg PO three times daily at 9:00 [NAME]M., 3:00 P.M. and 8:00 P.M.; -Aspirin 81 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (antibiotic) 500 mg PO daily at 9:00 [NAME]M.; -Vitamin D3 1000 units PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] 180 mg/24 hour extended release capsule PO daily at 9:00 [NAME]M.; -Dorzolamide 2% ophthalmic solution, administer one drop in the right eye three times daily at 9:00 [NAME]M., 2:30 P.M. and 5:00 P.M.; -[MEDICATION NAME] (antidepressant and antianxiety) 20 mg PO daily at 9:00 [NAME]M. -[MEDICATION NAME] sulfate 325 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (for nasal congestion) 100 mcg one spray in each nostril daily at 9:00 [NAME]M.; -[MEDICATION NAME] 20 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (used to prevent chest pain) 120 mg PO daily at 9:00 [NAME]M.; -Polyethylene [MEDICATION NAME] 3350 dissolve one packet in 8 ounces of liquid PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] (diuretic) 25 mg PO daily at 9:00 [NAME]M.; -[MEDICATION NAME] 0.5% ophthalmic solution one drop in both eyes two times daily at 9:00 [NAME]M. and 5:00 P.M.; -[MEDICATION NAME] (pain medication) 50 mg PO daily at 9:00 [NAME]M. Review of the resident's MAR for 1/6/19, showed: -12 out of 12 ordered PO medications not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] -One out of 1 ordered PO medication not administered at 5:00 P.M.; -The documented reason for not administering the medication: Not done resting in chair without anxiety; -Eye drops not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] -Nasal spray was not administered at 9:00 [NAME]M.; -The documented reason for not administering the medication: Not done due to not appropriate at this time. 10. Review of Resident #14's face sheet, showed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's POS, dated 12/2018, showed: -Menthol-zinc oxide (skin protectant) 0.44%-20.625% topical ointment to peri area (the portion of the body in the pelvis occupied by urogenital passages and the rectum) two times daily at 9:00 [NAME]M. and 6:30 P.M.; -[MEDICATION NAME] (antifungal) 2% topical powder to peri area two times daily at 9:00 [NAME]M. and 6:30 P.M. Review of the resident's MAR for 12/31/18, showed: -Topical creams not administered at 9:00 [NAME]M.; -The documented reason for not administering the medications: [REDACTED] 11. During an interview on 1/10/19 at 10:20 [NAME]M., CMT B said: -He/she was the CMT passing medications on 1/6/19 during the day shift; -There was one nurse, one CMT and three certified nursing aides (CNAs) for the entire unit that day; -There were a lot of residents that used a mechanical lift on that unit and he/she was continually pulled to the floor to assist the CNAs with getting the residents up since there were about 25 residents still in bed at the start of the shift; -He/she had two carts of medications to pass and did not have the time to pass them; -About 10 to 15 residents, mostly the front hall rooms 1-10, did not get their morning medications on 1/6/19 due to time restraints. It was after 11:00 [NAME]M. and the medications were out of the time frame to be given so he/she just stopped administering them; -The nurse and on-call supervisor were aware the medications were not administered; -The nurse spoke with the supervisor on call and the supervisor said to chart the medications were not administered and give the reason why; -This is not the first time he/she has not been able to pass all his/her medications due to staffing. During an interview on 1/10/19 at 10:55 [NAME]M., Nurse A said: -He/she was the nurse on duty during the day shift on 1/6/19; -The unit was short staffed on 1/6/19 with one nurse, one CMT and three CNAs; -He/she spoke with the supervisor on-call about the staffing issue and the supervisor said that the current staff is what the unit would have for the day; -He/she had two emergency situations he/she had to deal with and was unable to assist with passing medications and was unable to perform some of his/her treatments as well; -Approximately 21 out of 30 residents did not get all or part of their 9:00 [NAME]M. and noon medications on 1/6/19; -He/she had notified the nursing supervisor at 9:45 [NAME]M. that some of the residents did not get their medications, and the supervisor said ok and that was the end of it; -He/she did not call the residents' physicians and let them know that the residents did not receive their medications because he/she did not think about it; -He/she was off the next two days, but did not see any changes/harm to the residents when he/she got back to work on 1/9/19. During an interview on 1/11/19 at 10:35 [NAME]M. the Nursing Supervisor said: -There is no excuse for not giving medications. He/she expected them to be passed, no matter what; -If there is not enough staff, she expected staff to administer the medications late if they are once daily doses; -If medications are not administered, he/she expected staff to notify the physician and get orders; -He/she expected to be notified any time medications are not administered. During an interview on 1/11/19 at 10:50 [NAME]M., the Assistant Director of Nursing (ADON) said: -It was not acceptable for staff to not administer the residents' medications because they were running late; -One nurse, one CMT and three CNAs are sufficient staff for the work to get done and no residents should have missed any doses of their medications; -He/she was not aware the residents did not receive their medications and/or treatments on 12/31/18 and 1/6/19; -Facility policy is to call the physician if medications are not administered and get orders. During an interview on 1/11/19 at 10:58 [NAME]M., Nurse H said: -He/she was the nursing supervisor on call on 1/6/19, and he/she had been dealing with staffing issues all weekend; -He/she spoke to the CMT who said a few residents did not get their medications on time and that two residents did not get their medications due to it being well outside the range and close to the next dose; -He/she was not aware that 10 residents did not receive their 9:00 [NAME]M. medications that day; -He/she instructed the CMT to chart that the medications were not given and the reason why; -He/she is did not know if the residents' physicians were called; -He/she expected staff to call the physicians and let them know the medications were not administered. During an interview on 1/11/19 at 11:14 [NAME]M., the Director of Nursing (DON) said: -The DON, ADON, house supervisor and on-call supervisors are always available and he/she expected staff to notify him/her if resident medications are not administered; -He/she expected all medications and treatments to be provided per physician order; -He/she expected staff to notify the residents' physicians if they were unable to perform the medication administration or treatment for [REDACTED]. 12. Review of the facility's Medication Administration Policy, revised 10/2017, showed: -It is the facility's policy that medications are administered as prescribed in accordance with good nursing principles and practices, and only by persons legally authorized to do so; -Daily medications may be administered between 8:00 [NAME]M. and 12:00 P.M.; -Medications given more than once daily are administered within one hour before or one hour after the scheduled time. Routine medications are administered according to the established medication administration schedule of the facility; -No noted instruction for staff to notify the physician if a medication is not administered; -No noted instruction for what staff is to do if the medication was not administered within the established medication administration schedule of the facility. MO 459

Based on interview and record review, the facility failed to ensure one resident was free from abuse when three nursing staff held the resident down while a registered nurse (RN) performed a urinary straight catheterization on the resident, against the resident's will and against specific instructions from the resident's family, not to perform the catheterization for one of four sampled residents (Resident #1). The census was 102. Review of employee training records, showed RN A and certified nurse assistants (CNAs) E, F and G were all trained regarding resident rights which included the following: -Right to participate in one's own care with the right to refuse medication and treatment; -Tell the resident what you are going to do before you start. Don't start unless the resident agrees; -Right to dignity, respect and freedom from mental and physical abuse, corporal punishment and chemical and physical restraints; -All of the rights needed to be maintained at all times. Review of Resident #1's hospital history and physical dated 2/24/16, showed the resident's [DIAGNOSES REDACTED]. Review of the resident's initial nursing assessment dated [DATE], showed the following: -Facility admitted the resident on 2/29/16, with an admitting [DIAGNOSES REDACTED]. -Alert with both short and long term memory impairment; -Memory recall included year, month, day and season. Review of the resident's care plan dated 3/10/16, showed the following: -Incontinent at times; -Risk for urinary infection. Notify nurse for signs and symptoms of infection such as mental status changes, new onset confusion and irritability; -Forgetful, decreased decision making and safety. Introduce yourself each time you enter the room and explain what you are doing or what you want to do before doing it. During an interview on 4/1/16 at 2:24 P.M., RN A said on 3/25/16, the resident's family visited the resident and noticed the resident seemed confused. RN A offered to send the resident to the hospital because the resident had fallen on 3/17/16 and hit his/her head. The family said no and believed the resident may have had an urinary tract infection [MEDICAL CONDITION] because he/she had one before. RN A said they could do a clean catch (one of the least invasive procedures for a urine culture (test to determine what organisms cause the infection) or urinalysis (a test to analyze the urine for abnormalities) obtained by urinating into a container) to obtain the urinary sample and the family member (FM) said that was okay, but do not catheterize (insert a tube through the external opening into the bladder to obtain urine) the resident. The FM said do not catheterize the resident only one time and did not repeat do not catheterize. He/she told the staff to put a hat (a urine collection device) and a cup in the resident's room and try to collect urine from the resident. He/she got busy and never collected any urine, so he/she passed it on to the night shift nurse, RN C at 9:00 P.M. Review of the resident's nurse's notes, showed no documentation for 3/25/16 or the night shift of 3/25 through the morning of 3/26/16. Review of the resident's physician's orders [REDACTED].M., showed an order for [REDACTED]. Review of the resident's nurse's notes dated 3/26/16 at 11:30 A.M., showed the resident's FM called the facility, upset when RN A informed him/her, he/she was still unable to obtain urine from the resident since last night. The resident was incontinent. The FM requested the resident to not be catheterized. The RN tried to obtain a urine sample but the resident was unable to urinate due to increased agitation. Assisted resident to bed, and with a gender specific catheter inserted, obtained a scant return. In the meantime, the resident hitting staff and screaming and turning and throwing things at staff. Resident urinated earlier with a bowel movement, but unable to use that sample per the resident's physician. The RN called the FM with an update and suggested the resident go to the emergency room . The FM said, I will be right there. Two family members arrived and transported the resident to the hospital. At 12:10 P.M., RN A documented the resident sustained [REDACTED]. Further review of the resident's physician's orders [REDACTED].M., showed an order to send the resident to the hospital due to psychotic behaviors. At 12:35 P.M., an order for [REDACTED]. Review of the resident's transfer information form dated 3/26/16, showed the resident very abusive, hitting staff. Tried to straight catheterize with a gender specific catheter kit. Resident tried to remove the catheter, stated the staff were raping him/her. Review of the resident's hospital physician's progress note dated 3/26/16, showed the resident had been somewhat more confused than agitated. There was a concern about a UTI, the family requested a urinalysis. The facility notified the FM, they needed to use a straight catheter to obtain the urinalysis and culture. The resident's FM did not want a straight catheterization used on the resident. By the time the FM arrived at the facility, the resident had been straight catheterized with the help of three aides. The FM was very upset the catheter had been used against their wishes and the family took the resident to the emergency room . The resident's room mate recently moved and the physician was not sure if the recent changes may have caused the resident's increased confusion as his/her urine analysis was very unimpressive. The resident was alert and oriented to person, place and time, at the time of the physician's evaluation. During an interview on 4/1/16 at 2:24 P.M., RN A said when he/she arrived at work on 3/26/16, RN D gave him/her report and that he/she was unable to obtain a urine sample from the resident due to his/her incontinence all night. At 11:30 A.M., the FM called and yelled because the staff had not obtained a urine sample yet. The resident was in a wheelchair at the nurse's station when the FM called and the resident was yelling too. The RN felt pressured to obtain the urine sample. He/she had certified nurse's aides (CNA) E, F and G, put the resident to bed even though he/she knew the family did not want the resident catheterized. The resident was yelling and fighting the staff, but the RN felt it was urgent since the family was so hostile. He/she told the resident he/she needed a urine sample and would use a gender specific catheter. The resident was angry but pulled his/her pants down him/herself. The resident tried to beat up him/her when he/she wiped the resident off, so he/she had the girls hold the resident down. The resident was fighting so badly and the aides were trying to protect him/her (the RN). The resident was a large person and he/she could not see where he/she was going so he/she had CNA E hold the resident's legs apart, while CNA F and G held the resident's arms down on the bed at the wrists. He/she did straight catheterize the resident and obtained a small amount of urine, but it was not enough. The resident sustained [REDACTED]. He/she saw the skin tear when they got the resident out of bed to put him/her on the toilet. The resident did not want a bandage because he/she wanted the police to see his/her arm. The skin tear was approximately 1 centimeter on the left forearm. His/her intent was to get the urine, send it off, get the results, get the antibiotics and get the resident on the medication. He/she then called the FM and told him/her they needed to send the resident to the emergency room because he/she straight catheterized the resident and was not able to get enough urine and the resident was probably [MEDICATION NAME] (a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream). The FM yelled at him/her and said he/she told him/her not to catheterize the resident and asked who told him/her to do that. The FM refused to send the resident to the hospital because he/she and another family member were on their way to the facility. His/her intent was not malicious, he/she felt pressured; his/her back was against the wall. The resident was always wet and scalded down there. The FM said the resident felt like he/she had been raped. He/she used a gender specific catheter and offered to show it to the FM, but the FM declined. The FM only told him/her one time that he/she did not want the resident catheterized, the FM should have told him/her more than one time, if he/she meant it. The FM felt he/she violated the resident, but there was no bleeding in the genital area. The RN put [MEDICATION NAME] on the resident but did not wipe it off. The facility does review resident rights with the staff, but not regularly. When a resident is confused, the staff have to make decisions for them, but they do have the right to refuse treatment. He/she felt pressured, but should have called the physician and told him the family did not want the resident catheterized. He/she did not tell the physician this on 3/26/16, when he/she called for an order, because he/she knows the physician likes his residents to be straight catheterized. He/she should have left the resident alone and let the family yell at him/her or let the family come in and try to obtain the urine through a clean catch. If the family had not screamed at him/her on the phone, he/she would have just tried the clean catch all day. He/she was just as traumatized as the FM said the resident was. During an interview on 4/1/16 at 1:39 P.M., CNA G said on 3/26/16, the resident was at the nurse's station, screaming at his/her FM on the phone because he/she did not want staff trying to get anymore urine out of him/her. The staff tried to get him/her to urinate the day before. The resident gave the phone to RN A and who told the FM he/she was going to straight catheterize the resident. Then RN A got off the phone and told him/her and CNA E and F to go put the resident in bed. RN A started to put the catheter in the resident and he/she started kicking and hitting and almost hit RN A in the face and said, You better not stick that in me, you're not trying to help me. RN A told the aides to hold the resident down. He/she held the resident's left arm down and CNA E held the resident's right arm down and CNA F held the resident's legs apart. The CNAs held the resident's arms down against his/her chest, with both arms crossed at the chest. The resident punched CNA F in the stomach and that is when the resident sustained [REDACTED]. He/she held his/her legs out and upward. The resident said he/she was bleeding (from the skin tear), so RN A told the aides to move the resident's arm, but it was not bleeding, at that time. After RN A tried to get enough urine, but was not able to, the resident said, You already raped me, put me on the toilet. If I pee, I'll throw it in your face (RN A). Once the aides put the resident in the wheelchair, he/she apologized to CNA F for punching him/her in the stomach and then the staff noticed his/her skin tear was bleeding. He/she said the facility discussed resident rights when he/she was hired. Residents have the right to refuse a shower or therapy and he/she guessed not to be catheterized also. The resident did not want the catheter. The whole situation was crazy. The resident had not acted his/her normal self since 3/25/16, he/she was not sure if anyone reported it to a nurse. He/she only held the resident down when RN A put the catheter in. RN A probably should not have proceeded once the resident said no. The resident cried and screamed the entire time the staff held him/her down. The FM came in and looked at the staff, like the staff were the problem. During an interview on 3/30/16 at 11:40 A.M., CNA F said RN A was trying to get urine from the resident and needed help. He/she stood on the resident's left side, near his/her head and rubbed his/her shoulder and told him/her to calm down. The resident was screaming and hit him/her in the stomach, while swinging his/her arms. He/she stepped back out of the resident's reach and just rubbed the resident's shoulder. He/she did not hold his/her hands or arms. RN A was standing to the left of the resident trying to catheterize him/her and finally he/she got the catheter in and obtained a drop of urine. The resident was so loud; he/she could not remember exactly what the resident said and he/she was kicking his/her legs. He/she helped put the resident on the toilet afterwards and then left the room. He/she believed there were four or five people in the room, but did not remember who held what on the resident. A little later, staff must have put him/her back in a wheelchair because he/she wheeled him/herself down the hall screaming, help, help! CNA G took the resident back to his/her room. He/she was not sure if staff could make a resident do something they did not want to do. During an interview on 3/30/16 at 10:16 A.M., CNA E said RN A needed to straight catheterize the resident, so he/she, RN A and CNA G took the resident to his/her room and transferred him/her into bed. The resident pulled his/her own pants down and he/she did not hear the resident say no. The resident was agitated at the nurse's station and started fighting once in bed. At first, only CNA G held his/her hands, while the resident was kicking his/her legs. He/she then held the resident's right leg up so RN A could get in there to catheterize him/her. The resident was squeezing his/her legs together. It was not going well and the resident said, A rapist can get in, in one minute. RN A just couldn't get the catheter in because the resident was not cooperative. He/she left the room to get CNA F and they returned to the room. CNA G and CNA F held the resident's hands and RN A tried again. Eventually, he/she moved up to the resident's head, held his/her hand and talked to the resident. He/she gave up on holding the resident's feet. He/she could not remember what the resident was saying, but the resident was very upset; the nurse was not trying to hurt the resident. RN A got the catheter in and obtained a little drop of urine, but it was not enough. The aides transferred the resident to the toilet, but he/she was still mad and upset with them. He/she would not participate next time he/she was asked to hold a resident down and was not comfortable with him/her screaming. He/she wished he/she had never helped but the resident needed to be treated. He/she was helping and did not feel pressured to do so. He/she was not trying to hurt anybody. During an interview on 4/4/16 at 1:00 P.M., the FM said she noticed on 3/25/16 around 2:00 P.M., a change in the resident's personality. She asked RN A to get a urine specimen to see if the resident had a UTI and she offered to obtain the urine. She had just cleaned the resident up and he/she has no problem urinating. RN A said no, he/she would have one of the aides do it. She told the nurse not to use a catheter on the resident. She left at 4:30 P.M. and no one had been in to obtain the urine. She told RN A who said it was no problem, they will get it later. The next morning, on 3/26/16, the resident woke up in a panic and called her. The resident was talking strangely and screaming. She called RN A who said they had not been able to obtain the urine yet because someone had dropped the ball. It was supposed to be done the day before at 2:00 P.M. RN A said, he/she was going to catheterize the resident and she said no, another family member was on their way to the facility, he/she would get the urine. RN A said no, he/she would use a baby catheter and then did it anyway. She didn't want him/her sent to the hospital because the other family member was on the way there. Why did RN A do that, if you tell the resident to cough, he/she will pee. The other family member arrived and the resident told him/her what happened and that the staff held his/her arms and legs down. During an interview on 4/4/16 at 11:43 A.M., RN J said RN A called him/her on 3/26/16, after the family members left the facility that evening. RN A said the family was upset he/she had not obtained a urine specimen and they had been insisting since 3/25/16. RN A tried on 3/25/16, but was unable to because the resident was incontinent. RN A spoke to the physician and obtained an order for [REDACTED]. RN A told RN J he/she did his/her best judgement and had offered to send the resident to the hospital two times. As a nurse, RN A should not have catheterized the resident if the resident refused and the family said not to do it. He/she did not know the resident refused until 3/28/16, when he/she arrived at work. RN A made it sound like it was just that the family was upset. It is never okay to hold a resident's arms and legs down. He/she knew RN A had help, but did not know the resident was kicking and screaming until 3/28/16. During an interview on 4/5/16 at 7:48 A.M., licensed practical nurse H said staff should never hold a resident down for anything. All residents have a right to refuse treatment. Review of the facility's procedure for notification of the physician for change in resident condition dated 2/15, showed the following: -Licensed nurse will notify the physician when an individual experienced a change in medical status or condition; -Nurse will assess and document/report baseline information which included: -Vital signs; -Cognitive and emotional status; -Onset, duration and severity; -Nursing will contact the physician based on the urgency of the situation. Review of the facility's protocol for providing care dated 2/13, showed the following: -Ask permission to implement the procedure. If the resident refuses prior to or during implementation, stop immediately and notify your supervisor; -If the resident refuses, nurse or supervisor will speak with the resident to explain procedure, explain risks and benefits of not proceeding and ask for verbalization of understanding. Nurse will document refusal in medical record. Nurse will notify physician if applicable. During an interview on 4/5/16 at 1:08 P.M., the Director of Nursing (DON) said if a resident refuses treatment, the staff should not do it and should document it and call the resident's physician. It is more difficult to obtain urine if not using a catheter, but there are other methods of doing this and it might take longer to obtain it. RN A should not have had staff hold the resident down and catheterize him/her against his/her will. She was not aware the family member offered to get the urine and had told RN A not to straight catheterize the resident. She was not aware the resident had become combative and more confused on 3/25/16. RN A should have documented the change in condition and contacted the physician at that time and not wait until the next day if there is a change in condition. She was not aware RN A did not tell the physician the resident and family did not want him/her catheterized. During an interview on 4/4/16 at 1:36 P.M., the resident's physician said if the resident was showing a change in condition and behaviors on 3/25/16, the nurse should have called him then. Staff should always call when there is a change in condition. He was not aware the resident and the resident's family did not want the resident catheterized, if he had known, he never would have given an order to straight catheterize the resident. It would have been okay to do a clean catch. The staff should never hold a resident down to perform care, he was not aware a nurse told staff to do this so he/she could straight catheterize the resident. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility implemented corrective action to address and lower the violation at the time. During the on-site visit, the facility developed a plan of correction which included in-servicing all staff regarding abuse and neglect: identifying and reporting, resident rights, including the right to refuse anything including treatments and identifying and reporting changes in condition. They also inserviced all staff on contacting supervisors and required time frames to do so. Nurses were inserviced on notifying physicians when there is a change of condition or resident refusal of treatment and documenting the change or refusal and physician notification. Each oncoming shift, the nurse will review the shift report to ensure all incidents were followed up on. The nurse manager will monitor daily to ensure this procedure is in place. The nurse manager will monitor the shift report via email. Appropriate measures were taken to address the direct staff involved in the incident. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 146

Based on observation, interview and record review, the facility failed to immediately notify the administrator and report to the Department of Health and Senior Services (DHSS), an allegation of abuse by two charge Registered Nurses (RN), to a resident who resides on the memory care unit and to a resident who resided on the rehabilitation unit. The facility also failed to thoroughly investigate both allegations of abuse, in a timely manner and put interventions in place to ensure further potential abuse did not occur, while the investigation was conducted, by allowing the two RNs to continue to work, unsupervised for two of two sampled residents. (Residents #2 and #1) This had the potential to affect all residents. The census was 102. Review of the facility's abuse and neglect policy dated 12/15/13, showed the following: -Anytime an employee has reason to suspect a resident has been neglected, abused and/or exploited, the employee is to immediately contact their department manager. If after department hours, the facility on-call nurse manager is to be contacted through the on-site weekend or night supervisor; -The facility on-call nurse manager will notify the DON and/or the facility Executive Director; -Any person(s) observing an incident of resident abuse must immediately report such incident to the facility charge nurse or nurse manager; -It will be the responsibility of the facility nurse manager to initiate all department policies and procedures; -For allegations involving a facility employee, the department manager will contact the executive director and human resources to establish approximate next steps; -A complete written report of the Director of Nurses (DON)'s resident abuse investigation report must be provided to the executive director within 24 hours of the occurrences of such incident; -A complete written report of suspected abuse will be compiled for the executive director within five working days of the incident; -If the investigation reveals reasonable cause to believe the resident has been abused or subjected to conditions or circumstance which would reasonably result in abuse, the executive director will notify the DHSS within 24 hours of the suspected abuse notification; -Upon disclosure of alleged physical abuse, the resident will be offered a physical exam by the appropriate clinician. Thorough and descriptive documentation in the medical record of the injury are required. 1. Review of Resident #2's physician's orders [REDACTED]. Review of the resident's history and physical dated 2/21/16, showed the resident weighed 109 pounds (lbs). Review of the resident's care plan dated 3/14/16, showed the following: -Transfer assistance required two people. Remind staff to use a gait belt with transfers; -At risk for injury due to cognition and dementia. Assure resident is safe and free from abuse and neglect; -Altered mood state due to anxiety, cognitive loss and depression. Approach in calm, re-assuring manner and do not over stimulate resident. Review of the resident's nurse's notes dated 3/13/16 at 7:00 P.M., showed the following: -RN B documented, this evening, after a two hour nap-yelling to get up. Assisted to dinner-remained approx. ten minutes, requested to lay down-assisted down approx 30 minutes later after resident assisted with feeding and then requested to get out of bed ten minutes later. Complained of headache and then stated you hit me in the head, to RN B. Certified nurse aide (CNA) L stood at bedside, offered no assistance to transfer the resident from his/her bed, but witnessed transfer. Reporter applied a warm towel to the resident's neck and he/she told the reporter, you are the nicest person here. Supervisor, RN A made aware of resident's inappropriate comment -At 8:00 P.M., licensed practical nurse (LPN) K documented resident complained of headache and said, My head is hurting. RN B threw a shoe at me and hit me on the head, he/she is mean. He/she asked the resident what was wrong and the resident said he/she wanted to get out of bed, when RN B came in the room and threw me in the chair and hurt me. He/she talked to the resident and tried to comfort him/her. CNA L came and told him/her the same story like the resident had, that he/she was in the room and observed the whole situation. This was reported to the night supervisor. During an interview on 3/19/16 at 12:35 P.M., the resident said RN B helped him/her get out of bed. He/she guessed RN B was mad at him/her and asked the RN what was wrong but RN B did not answer. RN B took his/her shoes off but he/she did not want them off, so the RN took one of the shoes and hit him/her in the forehead. The RN was rough with him/her and he/she cried when the RN did it. He/she had a red mark on his/her forehead but it didn't bruise. I fear him/her, I try to stay out of his/her way. He/she told a couple of female nurses and the DON asked me about it and he/she told the DON what happened. He/she was able to correctly recall the current president and the current year. During an interview on 3/24/16 at 4:03 P.M., CNA L said on the evening of 3/13/16, the resident kept wanting to lie down and then yelled to get up; he/she did this over and over throughout the shift. Around 5:30 P.M., the resident wanted to get up again, so he/she went down to his/her room. The bed was in the lowest position and the remote would not make the bed go up so he/she could get the resident up. He/she went out into the hall and told RN B to come down to the room because he/she could not get the remote to work. RN B just snapped, he/she walked really fast down the hall, his/her face turned bright red and said, do I have to do everything? RN B came into the room, grabbed the wheelchair and put it by the bed. RN B did not try to raise the bed or test the remote to see what was wrong with it. RN B grabbed the resident's shoes off the floor and threw them onto the bed and one of them flew up and hit the resident in the forehead and he/she yelled out. RN B then bear hugged the resident and he/she yelled out as the RN threw him/her into the chair. RN B did not use a gait belt or ask for help. The RN asked, Can you find his/her glasses? Can you do that? He/she asked the RN if he/she was okay as the RN walked out of the room and pushed the resident up to the dining room. He/she did not know if the RN was upset with the resident or him/her. The RN was yelling at the resident earlier in the evening, telling him/her, he/she was not going to lay down. The resident normally has some confusion and gets scared and does not want to be left alone in his/her room. He/she told LPN K about it around 8:00 or 8:30 P.M. The RN worked the rest of his/her shift, until 7:00 P.M. and then left. He/she did not know if he/she should have reported when the RN yelled at the resident but when he/she physically threw the resident into the chair, he/she had to tell someone. During an interview on 3/19/16 at 2:29 P.M., RN B said the resident was restless all day, 3/13/16. He/she wanted to get up, if in bed and then wanted to go back to bed frequently throughout the shift. Around 5:30 P.M., a family member yelled from down the hall and said the resident needed help and his/her call light was also on. He/she saw CNA L standing in the hall, and told him/her to come with him/her to the room. The resident was seated on the edge of his/her bed and the bed was in the lowest position, about 8 to 10 inches off the floor. The resident is full weight bearing, but does not walk or transfer by him/herself. The resident was yelling, agitated and confused. He/she told the resident he/she had to get up or he/she would fall out of bed. CNA L then said the bed was broken and he/she said he/she would get the resident up. He/she took the resident's shoes off the floor and tossed them onto the bed, moved the wheelchair next to the bed, then reached around the back of the resident, under the arms and quickly stood him/her up and placed him/her in the chair. It was a fast motion because lifting someone who weighs 145 lbs, up from such a low position, he/she could have hurt his/her back. He/she put the resident's shoes on and wheeled him/her down the hall, to the dining room. CNA L just stood there and watched him/her; he/she did not know what to do. Once in the dining room, the resident started yelling for his/her glasses. He/she told CNA L to go get the glasses okay, it could have been sarcastic, like, if you can do that. He/she put a warm towel on the resident's neck and the resident said he/she hit his/her leg with his/her shoe. He/she told the resident, he/she did not, he/she threw the shoes on the bed. About 15 minutes later, the resident said his/her head hurt because he/she threw a shoe and hit him/her in the head. He/she called the supervisor, RN A and told him/her about the resident's comment that he/she hit the resident in the head with a shoe and RN A said the resident was confused, but to be safe, write a good note and check his/her blood pressure. He/she finished passing medications, worked on the nurse's note and waited for LPN K to arrive for his/her shift. The resident was seated next to him/her while he/she wrote nurse's notes. LPN K arrived at 6:30 P.M. and he/she told him/her what the resident said. The bed was not broken. He/she did not raise the bed or try; he/she could have raised it for a [MEDICATION NAME] transition for the resident and him/herself. He/she moved with speed because he/she was in such a low position. He/she did not tell the CNA to help because he/she was being very passive. The next time he/she worked after the incident, he/she worked on 3/15 and 3/16/16 and it was the same unit the resident lives on. During an interview on 4/1/16 at 2:13 P.M., RN A said he/she was working on another unit on 3/13/16, when RN B called him/her. RN B said a resident accused someone of hitting him/her. He/she told RN B to do a skin assessment of the resident and document it. He/she did not know anything else about it. He/she should have asked RN B more questions about the allegation, but he/she was involved in a lot of other things. RN B did not make it sound like a big deal; it was just a confused resident who made an allegation. He/she should have stopped what he/she was doing and ran over to the unit, but they have been super short staffed and he/she does not get a lot of support from management. He/she does not always listen at first. If it is a big deal, the person will come over to his/her unit and talk about it. RN B never called him/her back and he/she never talked to the resident because he/she did not know who the resident was until after DHSS left the building on 3/19/16. No one ever asked him/her to write a statement or talked to him/her about the incident. He/she did not report it to anybody that night. Staff are supposed to call their supervisor and put it in their report. He/she did not do that. If he/she would have known the urgency of the situation, he/she would have done that. He/she was RN B's supervisor on 3/13/16. RN B should have come over to his/her unit to talk to him/her. He/she would have taken it seriously if RN B had come over to talk to him/her. During an interview on 3/24/16 at 10:36 P.M., LPN K said he/she arrived at the facility on 3/13/16 around 6:30 P.M. RN B gave him/her report but did not say anything about the incident, only that he/she had gotten upset with CNA L and the resident had said something and RN B told the supervisor about it. Around 8:00 P.M., he/she went in to see the resident and he/she was holding his/her head; he/she had been having headaches. The resident said RN B threw the resident's shoe and hit him/her in the forehead. The resident did not have any marks on his/her head at that time. The resident said RN B had been mean to him/her before. The resident wanted to get out of bed and this upset RN B because the bed was not working. The resident repeated the entire incident and said there was one other person, standing behind the RN. After he/she talked to the resident, around 8:30 or 9:00 P.M., CNA L told him/her, the RN was upset because the resident wanted to get up. The RN did not ask for any help and picked the resident up without using a gait belt and threw the resident into the chair and threw the shoes at him/her. CNA L said the RN was enraged, his/her face was red and he/she was acting crazy. He/she then called RN D and told him/her what had happened. RN D arrived at the facility around 9:00 P.M. and talked to the resident. RN D at that time, told LPN K to write a statement and called CNA L to his/her office, to write a statement. The resident is oriented to his/her surroundings. He/she worked on 3/15 and 3/16/16 and the resident was upset because RN B had worked with him/her and he/she was terrified. The RN also worked on another unit on 3/22/16, he/she saw RN B working. The resident has some confusion but after a week, he/she was still telling him/her the same thing. He/she is afraid for the resident because nobody seems to believe the resident. During an interview on 3/28/16 at 9:35 A.M., RN D said on 3/13/16 around 8:00 or 8:30 P.M., CNA L knocked on his/her door and said LPN K needed to speak to him/her. He/she went over to the memory care unit and LPN K told him/her about the incident that had occurred earlier in the evening. He/she read the nurse's notes then spoke to the resident and then called RN N and informed him/her of the incident. The resident said he/she wanted to get up and the resident and RN B tussled. The bed was low, RN B hit the resident in the head with a shoe and then picked up the resident and threw him/her in a chair. The resident was afraid of RN B; the resident was making sense and was pretty clear about what happened. He/she believes the resident. He/she thinks RN B was aggravated with CNA L and the resident was in the wrong place, at the wrong time. He/she called RN N as soon as he/she found out about the incident; he/she called RN N because it was his/her unit, he/she was not the supervisor on call. RN B worked on the memory care unit on 3/26 and 3/27/16, he/she did not think he/she would have been allowed back to work. Review of an email dated 3/14/16 at 8:46 A.M., showed RN D emailed the DON and RN N and informed them of the incident which had occurred on 3/13/16. He/she informed them the resident was visibly upset, afraid and wanted to call the police. CNA L tried to raise the bed from the low position, but it did not work. CNA L asked RN B what was wrong with the bed and RN B came down the hall and said, My God, I guess I have to do it all. RN B's face was red and CNA L saw a piece of RN B, he/she had never seen before. RN B threw the shoes on the bed and hit the resident in the head with one of them and then picked the resident up and threw him/her in the chair. The bed was still in the low position. Review of the resident's nurse's notes, dated 3/14/16 at 8:10 A.M., showed RN N visited the resident and asked him/her how his/her weekend was and he/she said it was no good because his/her family did not visit. He/she had no bruising or bumps on his/her forehead. During an interview on 3/21/16 at 3:42 P.M., RN N said RN D called him/her the night of 3/13/16 and told him/her RN B hit a resident in the head with a shoe. He/she was not on call, RN D just happened to call him/her. He/she was confused about why RN D was calling because the resident was fine and RN B had left the building at the end of his/her shift, so there was no cause for concern. He/she told RN D to do what he/she wanted because he/she was there, RN D acted like nothing big happened. The next day, when he/she arrived at work, he/she went to see the resident. He/she did not ask the resident specifically about the incident, just how his/her weekend was. The resident said it was not a good weekend because his/her family did not visit. He/she checked the resident's forehead and there was nothing there. He/she did not know if he/she should have asked the resident specifically about the incident. He/she told the DON on 3/14/16, about the incident, when the DON arrived at the facility. The DON had RN D tell about the incident too. Staff are supposed to report to the DON immediately after something happens, investigate it and call it in to the DHSS if we feel abuse occurred. Looking back, he/she should have called the DON the night of 3/13/16, when it occurred. Review of a hand written note by the DON, dated 3/14/16, no time noted, showed RN B called her and said the resident had a headache all day and wanted up and down all day. His/her shoes did not hit him/her and CNA L did not do what he/she was supposed to do. RN B pivot transferred the resident, he/she was dead weight and went fast. RN B was worried that the resident might fall if he/she was left there because he/she was seated on the edge of the bed. Review of the resident's nurse's notes written by LPN K, dated 3/15/16 at 8:45 P.M., showed the resident held his/her head, pointed to his/her forehead and said, My head is hurting, RN B hit me with a shoe, in my head. The resident asked the nurse to leave the lights on, when he/she left the room, because he/she was scared. At 9:00 P.M., the nurse went back to check on the resident and the resident said, I'm scared RN B will come and hit me. Review of a note dated 3/16/16, no time noted, showed the DON and assistant DON met with RN B regarding the incident on 3/13/16. RN B said since they spoke on 3/14/16, he/she reviewed the events in his/her mind and could have handled things better. He/she would not have attempted to move the resident while the bed was in the low position. He/she was not as professional with CNA L as he/she should have been. RN B repeatedly apologized, said he/she did not hurt the resident and knew he/she could handle things better in the future. They told RN B the fact that he/she had insight into the events and his/her behavior was good and is how they can improve and become better in their jobs. They reminded RN B that he/she and CNA L don't work together often and that they were a team. Review of the facility's resident abuse investigation report dated 3/16/16, showed the following: -Incident occurred on 3/13/16 at 6:00 P.M. and reported at 8:00 P.M.; -No apparent injury reported; -CNA L reported the resident was getting in and out of bed all day long and RN B told CNA L to get the resident out of bed; -The resident's bed would not go up, CNA L went to get RN B and he/she said do I have to do everything around here? and got really red; -RN B picked up the resident's shoes, threw them at him/her and one of the shoes hit him/her in the head; -RN B then picked the resident up and threw him/her into a wheelchair; -On 3/14/16, in the early morning, RN N talked to the resident and he/she did not say anything about RN B throwing a shoe, hitting him/her with a shoe or throwing him/her into a chair. The resident did not say anything about the incident on 3/13/16 at 6:00 P.M.; -Interview with CNA L on 3/16/16 at 2:30 P.M., showed CNA L reported the incident as documented on 3/13/16. He/she thought RN B was out of control. RN B was upset, threw the resident's shoes and one hit the resident in the forehead. He/she did not think RN B intended to throw the shoe at the resident but RN B was upset and threw the shoe. He/she said RN B threw the resident into the chair; -Summary of the DON's findings: RN B said Do I have to do everything around here?. RN B put the resident's shoes on his/her feet. RN B threw the shoes onto the bed and one may have hit him/her in the head. RN B says the shoe did not hit him/her and CNA L said it did. RN B lifted the resident up and into the wheelchair. RN B lifted him/her fast and it was most likely a rough transfer for the resident; -Abuse did not occur, the resident had no injury and the DON did not believe RN B intended to hurt the resident. The resident wanted to get out of bed and RN B was mostly likely frustrated. It was not appropriate to throw his/her shoe or transfer him/her while RN B was upset; -Interview with RN B on 3/14/16, showed RN B reported he/she was upset at CNA L and felt he/she could have done several things differently; -This was a disagreement between staff members and did have a poor customer service outcome for the resident; -The DON notified the resident's family member and explained the incident. He/she was made aware the resident may have been hit with a shoe, by accident and had a rough transfer. During interviews on 3/19/16 at 12:20 P.M. and at 1:18 P.M., the DON said CNA L felt RN B did a rough transfer with the resident. RN B said he/she could have gone slower and done better. LPN K did not do a skin assessment on 3/13/16, after the incident, but did talk to the resident. The RN is a very good nurse and was just frustrated with the CNA about the bed. She spoke to RN B on 3/14/16 and then RN B worked the same unit on 3/16 and 3/17/16, 12 hours each shift. She spoke to the resident on 3/14/16, but did not specifically ask him/her about the incident, but she should have. She just knows that RN B would never do this. She did not call it in (to DHSS) because the resident was not hurt, had no bruising and abuse did not occur. She plans to suspend RN B and do a more thorough investigation. Review of an email dated 3/21/16 at 10:58 A.M., showed the DON emailed the administrator and informed her she had spoken to the resident. The resident told the DON it was March and it was a Monday (which was correct) and that RN B was mad at the resident. RN B seemed to be mad because the resident was on the other side. The resident had seen RN B at work and tried his/her best to stay away from him/her, RN B was not a pleasant person. The DON asked the resident if something happened with RN B and he/she said he/she did not like to be left in the big mansion with RN B, he/she dismissed all the help. He/she did not say anything about the event on 3/13/16 with RN B. The resident later said, How would you feel if you got hit in the forehead with a shoe. The resident said RN B hit him/her with a shoe but he/she thought it was an accident. The toe of the shoe hit him/her, RN B was upset and emotional because the resident wanted to get up and walk and he/she wanted to help. The resident did not think the RN wanted him/her to be independent. During an interview on 3/21/16 at 3:25 P.M., the DON said she spoke to the resident today and he/she repeated the incident to her. The resident thinks RN B was upset with him/her because he/she does not want him/her to walk. During an interview on 3/30/16 at 10:00 A.M., the administrator said she did not feel the incident was abuse after they reinvestigated, after the 3/19/16, DHSS visit. RN B is back at work. He/she was suspended all day 3/21/16, they finished the investigation and brought him/her back to work on 3/22/16. She is making sure he/she is not scheduled with CNA L. She discussed with the DON about whether to continue to let him/her work on the memory care unit, the final decision will be RN N and the DON's. She was not sure if anything had been done with him/her besides the conversation they had with him/her. RN B is really trying to do better after the incident. At 11:04 A.M., she spoke to the DON and they have decided to monitor him/her more closely over the next month or two. The DON told RN B if he/she was feeling stressed, to go outside or to the break room. She thinks RN B was stressed when the incident happened. During an interview on 3/30/16 at 11:40 A.M., the DON said she talked to RN B on 3/21/16, who said he/she was feeling good, in good spirits and learned from the incident, it was a positive thing. The managers discussed whether to continue to let RN B work on the memory care unit and they have decided to let him/her because he/she does a good job over there. She will check with families and residents after he/she has worked over there. RN B should have used a gait belt when he/she transferred the resident. She has not re-trained RN B on this since he/she returned and did not document anything to be put in his/her personnel file, but should have. Review of the DON's undated summary of corrective action, showed the following: -On 3/19/16, DHSS, investigated a complaint of resident abuse by RN B which occurred on 3/13/16 at 6:00 P.M.; -The facility suspended RN B on 3/21/16 and he/she returned to work on 3/22/16, after the facility completed the investigation; -The facility determined the incident was not abuse. RN B was upset with a coworker and his/her frustration resulted in poor customer service and a rough transfer of the resident, without the use of a gait belt; -On 3/21/16, the administrator, DON and nurse supervisor held a meeting and discussed RN B's return to work. They decided as a team, he/she should return to work. There would be follow-up interviews with coworkers, family members and residents, weekly during 4/16 and 5/16, to monitor for concerns; -On 3/22/16, RN B returned to work and reported he/she learned from the incident on 3/13/16 and there were times when he/she may need to slow down at work. Review of RN B's work schedule dated 3/13/16 through 3/22/16, showed on 3/13, 3/16, 3/17, 3/21 and 3/22/16, he/she was scheduled to work the day shift. Review of the shift assignment sheet dated 3/13/16 through 3/22/16, showed RN B worked every scheduled shift, with the exception of 3/21/15. Observation on 3/30/16 at 12:50 P.M., RN B worked on the memory care unit where the resident resided. 2. Review of Resident #1's hospital history and physical dated 2/24/16, showed the resident's [DIAGNOSES REDACTED]. Review of the resident's nurse's notes written by RN A dated 3/26/16 at 11:30 A.M., showed the resident's family member called the facility and was upset when notified that he/she was still unable to obtain urine from the resident since last night. Resident incontinent. The family member requested the resident to not be catheterized. The RN tried to obtain a urine sample but the resident was unable to urinate due to increased agitation. Assisted resident to bed and with gender specific catheter (a tube inserted into through the external opening to obtain a urine specimen) inserted, obtained a scant return. In the meantime, the resident hitting staff and screaming and turning and throwing things at staff. Resident urinated earlier with a bowel movement, but unable to use that sample per the resident's physician. Family member called with an update and suggestion the resident go to the emergency room . The family member stated, I will be right there. Two family members arrived and transported the resident to the hospital. At 12:10 P.M., RN A documented the resident sustained [REDACTED]. During an interview on 4/1/16 at 2:24 P.M., RN A said when he/she arrived at work on 3/26/16, RN D gave him/her report and said they were unable to obtain a urine sample from the resident due to his/her incontinence all night. At 11:30 A.M., the FM called and yelled because the facility had not obtained a urine sample yet. The resident was in a wheelchair at the nurse's station when the FM called and the resident was yelling too. The RN felt pressured to obtain the urine sample. He/she had certified nurse's aides (CNA) E, F and G put the resident to bed even though he/she knew the family did not want the resident catheterized. The resident was yelling and fighting the staff, but the RN felt it was urgent since the family was so hostile. He/she told the resident he/she needed a urine sample and would use a gender specific catheter. The resident was angry but pulled his/her pants down him/herself. The resident tried to beat him/her up when he/she wiped the resident off, so he/she had the girls hold the resident down. The resident was fighting so badly and the aides were trying to protect him/her. The resident was a large person and he/she could not see where he/she was going so he/she had CNA E hold the resident's legs apart, while CNA F and G held his/her arms down on the bed at the wrists. He/she did straight catheterize the resident and obtained a small amount of urine, but it was not enough. The RN said the resident sustained [REDACTED]. He/she saw the skin tear when they got the resident out of bed to put him/her on the toilet. The resident did not want a bandage because he/she wanted the police to see his/her arm. The skin tear was approximately 1 centimeter on his/her left forearm. His/her intent was to get the urine, send it off, get the results, get the antibiotics and get the resident on the medication. He/she then called the FM and told him/her they needed to send the resident to the emergency room because he/she straight catheterized the resident and was not able to get enough urine and the resident was probably [MEDICATION NAME] (a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream). The FM yelled and said he/she told him/her not to catheterize the resident and asked who told him/her to do that. The FM refused to send the resident to the hospital because he/she and another family member were on their way to the facility. His/her intent was not malicious, he/she felt pressured; his/her back was against the wall. The resident was always wet and scalded down there. The FM said the resident felt he/she had been raped after the catheter incident. He/she used a gender specific catheter and offered to show it to the FM, but he/she declined. The FM only told him/her one time that he/she did not want the resident catheterized, the FM should have told him/her more than one time, if he/she meant it. The FM felt he/she violated the resident, there was no bleeding in the genital area. He/she put [MEDICATION NAME] on the resident, but did not wipe it off. The facility does review resident rights with the staff, but not regularly. When a resident is confused, the staff have to make decisions for them, but they do have the right to refuse treatment. He/she felt pressured, but should have called the physician and told him the family did not want the resident catheterized. He/she did not tell the physician this on 3/26/16, when he/she called for an order, because he/she knows the physician likes his residents to be straight catheterized. He/she should have left the resident alone and let the family yell at him/her or let the family come in and try to obtain the urine through a clean catch. If the family had not screamed at him/her on the phone, he/she would have just tried the clean catch all day. The RN was just as traumatized by the incident as the FM said the resident was. He/she reported the incident to the DON after the family came back to the facility that evening. The DON did not answer and did not call him/her back until Sunday evening, 3/27/16. He/she then called the unit supervisor, RN J who said it sounded like he/she did what he/she could under the circumstances. He/she put it in his/her supervisor's report, wrote a nurse's note and wrote a five page statement and emailed it to the administrator on 3/30/16, when she asked for it. The administrator told him/her it sounded like he/she did what he/she could under the circumstances. During an interview on 4/5/16 at 5:30 P.M., the DON said she did not hear the phone ring when RN A called on 3/26/16. She called him/her back on 3/27/16 around 2:00 P.M., as soon as she saw the call. RN A made it sound like it was a family complaint, not that abuse had occurred. She did not know the staff held the resident down while RN A catheterized her. She asked him/her why he/she catheterized the resident when the family did not want it done and he/she said he/she felt pressured by the family mem(TRUNCATED)